Overlooked causes of chronically low vitamin D

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Vitamin D; overlooked causes of chronically low vitamin D, supplementation hype and sun exposure – Episode 6

How much vitamin D should you take? Does having higher vitamin D levels lead to better health? In this episode, Dr. Ruscio, DC investigates and explains the science behind vitamin D recommendations. He also answers the questions why taking more vitamin D might not be better and why we should all get out into the sun more often.

Vitamin D; overlooked causes of chronically low vitamin D, supplementation hype and sun exposure - Episode 6 - podcast artwork new

Introduction and background on vitamin D…..2:32
How pathogens can affect Vitamin D levels…..4:17
Low vitamin D levels correlate with poor health…..7:58
Vitamin D supplementation recommendations…..12:25
Ideal vitamin D levels – an ancestral perspective…..12:57
Intracellular infections and vitamin D…..14:59
Sun exposure vs. vitamin D supplementation…..17:20
Guidelines for healthy sun exposure…..19:35
Vitamin 25(OH)D and vitamin 1,25(OH)2D (calcitriol) levels…..25:30
Restoring vitamin D receptor competency…..28:10
Episode recap…..31:08


  1. (7:58) Vitamin D status and ill health: a systemic review in Lancet. http://www.ncbi.nlm.nih.gov/pubmed/24622671
  2. (13:38) A group of researchers traveled to east Africa to study the Maasai and the Hadzabe who live a hunter gather type of lifestyle. http://www.ncbi.nlm.nih.gov/pubmed/22264449
  3. (18:18) Is prevention of cancer by sun exposure more than just the effect of vitamin D? A systematic review. http://www.ncbi.nlm.nih.gov/pubmed/23237739
  4. (18:36) Exposure to sun may help to lower blood pressure. https://www.ted.com/talks/richard_weller_could_the_sun_be_good_for_your_heart
  5. (19:49) Endocrine Society clinical practice guidelines to vitamin D. http://www.ncbi.nlm.nih.gov/pubmed/21646368

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Vitamin D; overlooked causes of chronically low vitamin D, supplementation hype and sun exposure – Episode 6

Welcome to Dr. Ruscio, DC Radio, discussing the cutting edge of health, nutrition, and functional medicine. To make sure you’re up today on this and other important topics, visit DrRuscio.com and sign up to receive weekly updates. That’s D-R-R-U-S-C-I-O.com.

The following discussion is for educational purposes only, and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking to your doctor.

Now, let’s head to the show!

Susan McCauley: Hey, everyone. This is Susan McCauley, certified nutritionist from EvolveNutrition.com. Hey, Dr. Ruscio. How are you doing?

Dr. Michael Ruscio: Hey, Susan. I am good. Just trying to dig myself out of the pile of stuff to catch up on after taking off the holidays, you know?

SM: I know. I decided, over the holidays, to start a new business. (laughter)

DR: Oh, congrats.

SM: Yeah, Kendall Kendrick from Primal Balance, and I started a podcast on recovery – like drug and alcohol addiction. We started a whole company.

DR: Awesome.

SM: So, we’re calling it EvolvedRecovery.com.

DR: Sweet. Well, I am sure that’s going to help a lot of people.

SM: Yeah, yeah. It’s not…it’s kind of for everybody. It’s very basic, so, you know, it’s not a high technical, you know, podcast. It’s a very basic – sleep, good food, that kind of stuff.

DR: Sure, I like it.

SM: Yeah. So how about yourself?

DR: Well, just trying to get some of these notes together from the thousand-and-one thought I have regarding vitamin D, which is going to be our focus for today.

SM: I know. Vitamin D, like, it just seems crazy all the different recommendations that have been, you know – since I’ve been in the health and nutrition bill for four years – the recommendations have just changed all over the map, and everybody has their own recommendation.

DR: Right. Well, hopefully today we can provide people with kind of a framework for why the disparity between recommendations exists, and how to navigate this. Because I think that I’ve got some answers for people in that regard. So, hopefully this will help people, again, just understand why some people say one thing, some people say the other thing, and how can we kind of sift through that.

SM: Yeah, and what the research says.

DR: Yeah, absolutely.

SM: OK, fill us in.

DR: All right, so. Like you alluded to, there is this background surrounding Vitamin D where, for awhile there, it was like the wonder nutrient, or the wonder hormone, right? Everyone was talking about it, was excited about it, recommending, supplementing as high as you can to the upper end of the reference range, maybe. Upwards around 100. I remember following some of the literature from the anti-aging community. They were super jazzed about it, citing the studies of lifeguards who had the Vitamin D in the 70s, 80s, 90s, and how that’s what we should all shoot for, and yada, yada, yada. So, that’s kind of more of the more historical context. But then, more recently there’s been a rethinking, by some people anyway, there’s been a rethinking of, ‘Should we really be supplementing to get levels that high?’ And I think some of that is based upon looking at the information and saying, ‘Well yes, observational studies show that people who have low Vitamin D have a higher incidence of various, different diseases. But that doesn’t mean that supplementing to higher levels of Vitamin D are going to produce the same outcome that’s observed in someone who naturally has high levels of Vitamin D.

SM: Right. It’s like, we always think, and the pharmaceutical industries do this too, is like, let’s just single supplement one thing to make a number go up and somehow that’s going to miraculously cure everything.

DR: Right, and I just want to put the concept out there right now lay some foundation, and come back to the concept in more detail. But the reason why that may be is because in people who are sick, that have low Vitamin D, there may actually be infections or an infection that are actively converting Vitamin D into the metabolite of Vitamin D called calcitriol or 125 Vitamin D.

SM: Uh-hum.

DR: So, what happens here essentially is certain pathogens will modulate their Vitamin D receptor to evade the immune system. And what happens in that process is your body burns through Vitamin D to produce the metabolite 125 Vitamin D. And what you’ll see with these patients or these people, is you’ll see a normal or little bit lower of a Vitamin D. But, if you also test the metabolite 125 Vitamin D, you’ll see that high. And, that’s something I’ve been monitoring in the clinic, and I’m certainly seeing that in the cases. For example, the first few cases that I did this with, Vitamin D in one gal came back at 59, the 125 came back 113. That’s a big discrepancy, and the value should be maybe be roughly the same. But we’ll come back to that in a little more detail, but…

SM: Quick question: So, I’ve always been taught that the 125 was the active form of Vitamin D. Is that correct?

DR: Well, yeah, I think that is true. It depends on what you’re quote/unquote active…

SM: Well, what your body uses.

DR: It is the form that, essentially, this gets transferred via the Vitamin D binding protein, and gets transferred into the nucleus, where it binds with the Vitamin D receptor.


DR: Yes, so it has more of functional role, I guess, than regular Vitamin D.

SM: OK. So then, when your body’s converting it to the metabolite – so, you think with people with the infections, the research shows that, and with your clinical experience, that it’s just converting it at a greater pace? Your body is sensing that it needs more, so it’s converting more?

DR: Nope. It’s not that your body needs more. This is not a good thing. This is pathogens manipulating your Vitamin D receptor in order to suppress your immune system so that they can live.

SM: Ah, OK. That makes sense.

DR: The theory is, if you take more Vitamin D, you may actually fee – you’re giving bullets to the pathogen’s gun, so to speak.

SM: Uh-huh.

DR: So, you’re pouring gas on the fire if this process is in play. And this may answer the question why some people say, ‘I keep taking Vitamin D, and my Vitamin D levels never go up. And, I think that’s why sometimes I’ll see in a patient a Vitamin D at a 35 and then a 125 Vitamin D at 135. So, let me paint some of the context for why I think this is, because, depending on who you are listening to this, this may seem very controversial to you, especially if you’ve been heavily educated in the model of Vitamin D as a wonder nutrient. So, there was a really good systemic review published by…in the Lancet. And, we’ll have the reference to this is the show notes. So, a systemic review, just as a quick recap, is where a group of researchers look through multiple other studies and try to, essentially, summarize several other studies and come to a conclusion. So, it’s a much stronger piece of data than just one study,

SM: Is that the same as a meta-analysis?

DR: Meta-analysis is similar. A meta-analysis will do a similar thing – they will look at multiple, different studies. But a meta-analysis usually goes through more of statistical workup to see if one treatment worked or didn’t work. So, in a meta-analysis, you’ll see a lot more of a statistical analysis of treatment compared to control. In a systemic review, it’s similar, but it doesn’t have the heavy-weighting for the stats. It’s just more so looking at what is the average finding of the data, so to speak.

SM: OK. That makes good sense.

DR: Right. So, again, this is a systemic review. It carries a lot weight. I’ve given this paper a fairly good shake, and they’ve gone through a lot of studies to come up with these conclusions. So, there are two quotes I’d like to read from this paper:

“Results from interventional studies did not show an affect of Vitamin D supplementation on disease occurrence, including colorectal cancer…”


“The discrepancy between observational and interventional studies suggests that low Vitamin D is a marker of ill-health. Inflammatory processes involved in disease occurrence in clinical course would reduce Vitamin D, which would explain why low Vitamin D status is reported in a wide range of disorders.”

SM: That really points to the fact that, just because you have one – if your Vitamin D is low, just raising it isn’t going to get you healthy. It’s just showing that you have poor health.

DR: Exactly. So, the key thing, in case that sounded a little bit like gibberish is, there is a discrepancy between what we see in observational studies compared to interventional studies. Observational data, when we look at a population of healthy or sick people, we definitely see the- the general trend shows low Vitamin D correlates with disease. However, when we go to supplement people with Vitamin D, it doesn’t seem to consistently translate to health outcomes. So, that tells you the solution to that problem is not Vitamin D supplementation, per say.

SM: Right.

DR: So, that was in the Lancet, 2014, very well done paper. That’s not to take anything away from using Vitamin D. I think Vitamin D has place and a role. But, what I hope this will dissuade people from doing is – the person out there who is listening to this, or reading the transcript of this, who is not feeling well, who has just been mega-dosing themselves with Vitamin D. I hope this person will stop because they might be making themselves worse.

SM: Right, especially when it comes to things like cardiac health, correct?

DR: Right, yep. And especially if Vitamin D is not taken with Vitamin K. High Vitamin D can be problematic, of course, because it can increase calcium levels. Now, it’s not clear to me, at least based on my examination of the literature, whether – if you have an infection and the infection is causing this whole issue we discussed – if that could have deleterious effects on your heart health. It doesn’t appear to be that way because this high 125 Vitamin D doesn’t seem to always be accompanied by high calcium levels in the blood, as you expect if that were the case. But, if people are taking Vitamin D, it is important that they take Vitamin D with Vitamin K. I’ll come back to that when we go through some recommendations on how to optimize your Vitamin D levels. But the short snippet there is: Usually for every 2000 IUs of Vitamin D, I like to have an accompanying 50 micrograms of Vitamin K, too. Or, if someone is taking Vitamin D, that at least need to add on 100-to-150 micrograms of Vitamin K, too, per day. We can come back to that in a minute. There is one other thing that I want to kind of outline that helps us understand this whole Vitamin D controversy piece. What are the ideal levels from, maybe, observing Hunter/Gatherers? Right, because this is a piece that I think could be really helpful, especially for people in the paleo or the ancestral framework – looking at how our as-healthy-as-they-could-be assessors lived. And, what health lessons can be derived from them. So, we don’t have any way to at least that I’ve come across of knowing what Vitamin D levels were for someone in the Paleolithic.

SM: Right.

DR: But we can look at modern-day Hunter/Gatherers, which is our best second proxy. So, a group of researchers – and we can include the link to this study also in the show notes – went to study the Masai and the Hasibe tribes. And I hope I’m pronouncing both of those right. And they found average blood levels in these groups fairly untouched, unaltered Hunter/Gatherers of 46 micrograms-per-milliliter. So, that finding is a little bit more in line with the more-contemporary, conservative viewpoint on Vitamin D, which is, you know, 80-ish not the scale might be too high; somewhere in the range of 30-40 might be a little bit healthier, might be a little bit safer. Does that make sense?

SM: Right, yes. I’ve always thought, when they changed – when they moved it to the 80, and I’ve even heard some people say, ‘Just get it as high as you can.” It just never felt right with me. It just never sat right that we should try to get things as high as possible. It’s kind of like the statins – ‘Let’s get your cholesterol as low as possible,” just doesn’t sit right with me, either.

DR: Right, I agree. I think very rarely in biology is a more-is-better approach the ideal way to go. There is usually always some kind of negative tradeoff for that.

SM: Exactly. So, I just want to back up real quick. You kept mentioning infections a few times. Do you want to fill everybody in on what type of infections you are talking about?

DR: Specifically, these are intracellular infections, or what’s called cell wall deficient, or maybe more technically, cell membrane deficient infections. These are essentially infections that can inside your cells. These are infections that live inside the cells of your body – like red blood cells, white blood cells. Now, there are a number of them, mycoplasma pneumonia, chlamydia pneumonia, mycoplasma tuberculosis, Aspergillus – certain members of the Aspergillus family – are these types of intercellular infections. Some of the Lyme in Lyme co-infections. One the things that I’m doing, I wish there was like an easy answer to that. Let me back up. I guess the easy answer to that is, they’re not some of your more-traditional infections that you hear about, like candida, SIBO, worms, giardia – those are not intracellular infections; they don’t live inside of your different cells in your body.

SM: Right. Those are gut infections.

DR: Right. So, the ones that are, are some of the Lyme family, and Lyme family co-infections, and certain viruses. And one of the things that I am working to do right is put together a panel that will screen for some of the most common intracellular infections, so that when we see a patient that has this disparity between Vitamin D and 125 Vitamin D, we have a good follow-up panel to help us weed that out.


DR: Yeah, but thank you, yeah, because that’s an important thing to mention. It’s not any and every infection. It’s specifically intercellular infections.

SM: So, if somebody does a stool test with their GI doc or their functional medicine person, they might not have been tested for these infections.

DR: Exactly, right. Now the other thing I wanted to just touch on was – There is an important point regarding Vitamin D. One of the things I’ve been looking into is does Vitamin D supplementation garner health benefits, or could it be exclusively from sun exposure? Because, that’s another layer of this whole piece, which is, OK, some of these healthy people have higher Vitamin D. Now, what’s the best way to try to get back, right? One way, definitely, addressing any kind of infection, like we talked about. But, it also may be that you just need to get more sun exposure, right? It may not be that you can supplement your way out of the problem. You may need to lifestyle your way out of the problem, right? And, the main thing that I just want to highlight here is, there gave been some studies performed that have shown health benefits of sun exposure that were irrespective of one’s Vitamin D levels. Now, specifically with prostate cancer, non Hodgkin’s lymphoma, and also with blood pressure – it’s been shown that those all experience benefit from sun exposure, but it does not correlate with Vitamin D status. `

SM: Ok, so sun exposure as in just going and walking outsider, or sun exposure as in actually laying out in the center using a tanning bed?

DR: Well, they don’t specify, because this study that I’m referencing here – and we’ll put in the show notes – is another systemic review. So, these are looking at a number of different studies…


DR: …and so, it’s really hard to say it was one type of sun exposure. I doubt it was from tanning beds, just because I think the researchers usually have a little bit of bias of…you know, you can’t really recommend tanning beds because of ethical reasons. So, it’s probably just from natural sun exposure outside. But, that’s actually a very good segue into one of the things I wanted to touch on, which is what are some parameters, some guidelines for obtaining healthy sun exposure so that you can get appropriate Vitamin D levels? Because that’s something that people are probably going to be curious about. I went through the Androgen Society’s position paper for 2014. And, the Androgen Society essentially lays out what they feel is an acceptable amount of Vitamin D that one should be getting into their systems, either via supplementation or via sun exposure. I went through their numbers, and I broke down some of their calculations to come up with, ‘OK, hey, how much time do I have to spend in the sun to get adequate Vitamin D exposure?’ There are two different ways of looking at this: If you’re wearing a bathing suit getting full-body exposure, or if you are just exposing your arms and your legs. So, if you’re wearing a bathing suit, and you are Vitamin D deficient, a treatment dose would be one minimal erythemal dose three days per week. Now, a minimal minimal erythemal dose is enough sun exposure to cause a light pinkening of the skin.


DR: So, it’s just enough to kind of know you were in the sun, right? So again, if you’re wearing a bathing suit, treatment exposure is one MED three days a week; maintenance dose is one MED one day per week.

SM: Wow, so not very much at all.

DR: Yeah, yeah. So they vary a little bit less and a little more depending on the pigmentation of your skin, right? So, just something for people to keep in mind; they may want to get a little more, a little less than that depending on if they are very fair skin or very dark skinned. Darker-skinned people may need a little more, lighter-skinned may need just a little bit less. If you are exposing just your arms and your legs, if you’re deficient, you would need one MED seven days per week. And, for maintenance, you would need one MED 2.5 days per week.

SM: OK. So, you and I are both lucky; we live in Northern California, where it’s sunny quite often. What if you live in Seattle, where it’s not sunny most of the time? You won’t be able to get that sun exposure.

DR: One of the lines of thinking I recently came across in reading up on this issue that made sense to me was, as long as one gets adequate exposure throughout the more bright months – summer, spring – then one should be able to store adequate Vitamin D through the darker months in their liver and their fat stores.

SM: So, when it’s sunny, get outside.

DR: Definitely, get outside. And maybe a good guiding principle for people would be, as soon as the spring starts, have your Vitamin D level tested. Figure out if you are deficient or if you can go into maintenance mode. And then, choose the corresponding level of exposure based upon if you’re in treatment mode, or if you’re in maintenance mode.

SM: OK, Then I’m going to step into the controversial arena, like I said. With a tanning bed, and, say, we are probably not supposed to be wearing sunscreen when we’re doing this sun exposure or are we? Because, you know, the American Medical Association and the American Cancer Society say we should be wearing sunscreen anytime you leave the house.

DR: Right. Well, sunscreen, in my understanding from the examination of the literature – although there is a little bit of controversy surrounding this – sunscreen does dramatically decrease your Vitamin D production. And that opinion was even echoed by the Androgen Society, which is as conventional and conventional as you get. So, if you’re following these dosing parameters, I think you’ll be all right, because the important thing is not to over-expose yourself to sun, and also not to burn. So, these recommendations, with obtaining the MED, it’s just enough sun exposure to know that you got some sun, but not anywhere near enough to burn.

SM: Right.

DR: So, certainly I think these recommendations here are highly conservative from one of the most conservative medical bodies in the world. I think anyone will be able to obtain these levels without sunscreen, without having to have any major worry about skin cancer, although that’s always something that you’re going to want take on a case-by-case basis, depending on your medical history and everything else.

SM: Right. So, just remember that it’s the sunburn, not the sun exposure, that’s the cancer risk.

DR: Yeah, and/or over-exposure, right? Which is why these guidelines are nice, because it gives you – again, to be very conservative – what is the minimal amount I need to maintain the Vitamin D health benefits – it’s the minimal you need to get by; if you get that, then you’ll get the benefit, but you don’t have to worry about overdoing it and potentially damaging your skin in the process.

SM: And then, what about foods that contain Vitamin D? Should you focus on getting the foods that contain Vitamin D?

DR: I think it’s really hard for people to get enough Vitamin D from food, to be honest with you, which is why I think people really should get it from the sun. The other reason why I say that is, again, because some of the literature is showing that there are health benefits from the sun that you don’t get from ingesting Vitamin D.

SM: Great, OK.

DR: So, I think that’s some of the main points I wanted to hit. Now I just want to kind of circle back to the issue of this Vitamin D, 125 Vitamin D. And 125 Vitamin D: You may see it also as calcitriol. I just like the 125 Vitamin D; I think it’s a little bit cleaner. So, with Vitamin D, a good range I think to be in is maybe around 40-45. I think that is reasonable. And, I think that for the 125 Vitamin D, that’s a good number to also achieve. Now, if you look at, for example, LabCorp and Quest, their upper end of their reference range is about 72, 75. But also for LapCorp and Quest, their upper end for Vitamin D is about 77-to-100. So, I think the reference ranges are, maybe, a little bit too high. So, I think having something around 40-45 for both 25 and 125 is probably ideal. If you’re healthy, and you get a little bit of sun exposure, and, maybe, a little bit of Vitamin D supplementation to get your levels up a little bit while you sun exposure falls short, that’s balanced with Vitamin K. You should be fine and not really have a whole lot else to worry about. But, if you’re sick, and you have some kind of chronic health complaint, and you’re getting some sun exposure, maybe doing some responsible Vitamin D supplementation – maybe 2,000-to-6,000 IU a day, more than that – and your Vitamin D levels never budge, then you definitely should have a look at your 125 in tandem. And, if your 125 is high, you should stop with the Vitamin D supplementation, and get yourself to a clinician who can figure what’s causing that high conversion of 25-to-125.

SM: Yeah, get this panel that you’re going to come up, that looks at these intracellular infections.

DR: Exactly, yeah.

SM: And then, the treatment? Do we even want to get into the treatment of these intercellular infections?

DR: Well, really it’s way beyond what I think we can cover here, but one of the things I think may be important to mention is, with the treatment, you, of course, want to treat the infection itself. And then there are also agents that can be used to help restore Vitamin D receptor competency. Because, it’s the corruption, if you will, of the Vitamin D receptor by these pathogens that causes this problem. So, we both want to clear the pathogen, but also, if we can do some stuff to help restore Vitamin D receptor competency in the short-term, that’s going to be really helpful. There are some natural and prescription options that are available for this. Resveratrol has actually been shown to help mitigate some of this Vitamin D receptor compromise. Some omega-6 may have this ability, some arachidonic and/or linoleic acid, and also cucuman may have this compound. I think Resveratrol is probably the most well studied in this regard, although I’m not an expert on this specifically, per say. And, there’s also a prescription known as olmesartan. This essentially works along the same lines to help restore your Vitamin D receptor competency. And one of the interesting facts that’s been noted about this prescription approach, is that it actually is accompanied by a die-off reaction. It’s purported because it can work so strongly at restoring Vitamin D receptor competency, that the immune system is now no longer abated by the pathogen. It starts to kill the pathogen, and you have a die-off reaction. So, I don’t have any experience with olmesartan in this regard. But, depending on how things shake out in the future, we may start using it in the clinic.

SM: Why don’t you fill us in on what actual die-off symptoms are.

DR: So, die off is just feeling kind of yucky. You can have a headache, flu-like, irritability, tired – those are some of the most common symptoms. Essentially, as pathogens die, they release small amounts of biotoxin. And, those toxins can make you feel kind of yucky.

SM: It’s our body’s way of getting the bad stuff out. Some kind of side effects and then you probably feel awesome afterwards.

DR: Right, yeah. And some of that may also be through cytokine and inflammatory modulation, also. Yeah, but it’s just kind of part of the process of getting over an infection. That’s why some flu that you have, for example, will cause you to have a really bad fever and have a headache – Because it is part of the immune response.

SM: So, we’re coming up on 30 minutes. Do you have anything else to share with us?

DR: Well, I am happy we got this one pretty much dialed in. I think that’s most of what I wanted to go through, and we’re coming up on 30. So, perfect. But just a quick recap of some of these concepts, I guess. Vitamin D has been controversial. Some people say you need a ton, some people say be a little more careful. I think we’ve shown that the confusion comes from the fact that we can’t take observational data and translate that into, ‘OK, that means were have to supplement with a bunch of Vitamin D. So, I think that’s part of the content here. And then also, part of the other context may be that people that are sick and have low Vitamin D, the Vitamin D may be secondary to an infection, and it may not be the actual cause of the sickness itself. And, then we laid out some guidelines for how to obtain Vitamin D exposure from the sun, and gave you some preliminary steps on what to look for if you think this Vitamin D-to-125-Vitamin-D-conversion problem may be at play. And, hopefully that’s enough for people to get moving on the right should they have it. So, that’s the general recap. If you guys have questions, feel free to post them and will do our best to try and respond.

SM: And then, also your supplementation – if you do supplement, make sure that you don’t just supplement with Vitamin D, that you want some Vitamin K, too.

DR: Exactly, yes.

SM: OK, OK. That’s a wrap.

DR: Well, awesome. Well, thanks, Susan. We’ll talk to you next time.


DR: OK, by-bye.

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