Wednesday 25 September 2013

Vitamin D, the Sun and sporting success - Sir Alex Ferguson's view

Sporting success is of immense importance to very many people. The management challenge is how to maximise it.

Success seems to come from living at high altitude, Ethiopia being a prime example. One way of interpreting this is that the atmospheric pressure is lower and thus the availability of oxygen. The body must compensate by improving metabolic efficiency, including heart function and the number of red blood cells. Such people acclimatised to high altitudes would then have an advantage when performing against athletes and other sporting people living at low altitudes.  European athletes are now often sent for high altitude training.

Another interpretation is that at high altitudes there is much greater sunlight energy than at sea level. Perhaps the sun is an important factor. We have seen in a previous post that living at high altitude has important health advantages and this is due to more sun energy, like living closer to the equator.

It is also interesting to note that leading sportsmen have a higher than expected frequency of births in the late autumn and early winter (in the northern hemisphere). There are other examples of the advantage of an autumn birth. It seems to be the result of the mother's pregnancy during the summer, thus maximising transfer of vitamin D across the placenta. The importance of the sun and vitamin D is quite remarkable.

Sir Alex Ferguson, manager of Manchester United until recently, became aware of the importance of  vitamin D, and rather than sending his players for long and regular excursions to high altitudes, he installed tanning booths in the training centre. He realised that the weather in Manchester UK has little sunshine and he needed to provide regular controlled ultraviolet light to his players to substitute for the sun and thereby to improve their vitamin D levels and their physical performance.

This appeared as part of an investigation into Ferguson's managerial success in the Harvard Business Review. 

It was reviewed in the Daily Mail 

Wednesday 18 September 2013

What your doctor might know about vitamin D

For many years, in fact for all of my working life since my medical graduation in 1966, I have been aware of the inequalities of health.

Southern Europe
Why is it that life is shorter and health worse in people living in the north-west of the UK compared to the south-east? There is also worse health in northern Europe compared to southern European countries. These are facts and have been the case for many years. They remain true today, and officially this is not understood. It is mistakenly blamed on the people themselves - victim blaming, people in the north eat the wrong foods and do not live healthy lifestyles. This is very convenient as it transfers responsibility away from government, which is a guardian the health of the public, on to the people themselves. It is part of the present obsession with "lifestyleism". We know that although there is a considerable difference between the health of people in the north-west of the UK compared to those in the south-east, there is no difference in what they eat.

Northern England industrial town
There is also the inequality of social class - poor people have shorter lives and more illness than wealthy people. This is also blamed on the people themselves, very conveniently. It might be more the result of their housing and overall environment.

And the there is inequality of ethnic minorities in the UK, who have shorter lives and more illness. Dietary indiscretions are difficult to sustain as they are so varied. Once again their health is worse if they live in the north of the UK rather than the south.

My research led me to believe that the inequalities are the result of variations of sun exposure - less sun more illness. This is the result of residence more distant from the equator, socio-economic disadvantage, and living in northern locations with ethnic origin closer to the equator.

This has not yet entered conventional wisdom, but there is increasing awareness. This can be appreciated from the increase in blood tests for vitamin D.

However there is still a medical view that vitamin D is necessary for healthy bones and the avoidance of rickets, and that is all. There is a lack of awareness that vitamin D had any other effects, such as the development of immunity and the control of genes. There are important health advantages to people with high vitamin D levels (ideal range) but theses are generally unknown. One of the problems is that vitamin D has no commercial backing. The financial and organisational power of the pharmaceutical industry must not be underestimated. I am not against the pharmaceutical industry, which has provided so much, but I feel that it has too great an influence on medical education. This is perhaps a criticism of doctors themselves , many of whom seem to obtain most of their medical education from the pharmaceutical reps and their highly prejudiced sales brochures. No-one is marketing vitamin D, and knowledge of it depends on doctors reading medical scientific journals.

And so a visit to a doctor to discuss vitamin D can be very frustrating.

This YouTube might be a bit extreme, but it might happen to you ....

Doctor, should I take vitamin D?

Wednesday 11 September 2013

Italy - a land of good health

The challenge facing the UK government is that the health and life expectancy of its population are not as good as in many other countries in Europe. The health of the public and the completeness of health services is now a responsibility of government in all European countries, but many aspects of health are beyond government capabilities.

In the UK the government still remains under the impression that it should be able to fix all health problems, and this is thus the expectation of the public. When the NHS was introduced in the UK in 1948, Aneurin Bevan, its architect and first Minister of Health, stated that "even when a bed-pan is dropped it will be heard by the minister in Whitehall". This set the scene for an over-centralisation of responsibility which subsequent ministers have been trying to dismantle. However the people look to the government when things go wrong and when standards are not as high as expected.

The UK government cannot avoid the fact that the population of Italy seems to have better health than that of the UK. There are fewer heart disease deaths and cancer deaths per 100,000 population (age-standardised). There are better survival rates for various cancers, that is time from diagnosis to death. Remember that the cause of death is the closest that we can get to health truths. Recording of illness in
the living is very variable. It depends on local nomenclature and there are reporting variations from country to country.

Take for example Modena in northern Italy. Modena is the home of Balsamic vinegar, Ferrari and Masserati cars, and a large derelict tobacco factory. It is a pleasant city like so many in Italy and it must be a delightful city in which to live. A European study shows that survival from colon cancer is highest in Modena. This was judged as the percentage of those diagnosed with colon (bowel) cancer who were still alive after three years, and it was 64% in Modena compared to 47% in London (Thames).

The medical services in Modena take the credit for this achievement, but to paraphrase Voltaire, is this just doctors taking the credit while nature brings about the cure?  Does Modena really have the outstanding medical services that lead to it having the lowest mortality from bowel cancer in Europe? Or is it because Modena is in Italy? And in Italy we can also see low death rates from heart attacks and other cancers compared to the UK.

I do not believe that it is bad medicine in the UK that leads to poor health performance figures any more than I believe that Italy and other southern European countries have more excellent services. Voltaire was right! Nature is of the greatest importance, and within nature it is the sun that controls much of our health and death.

We see a similar effect in the UK itself. Survival rates from colon cancer are better in the southern parts than in the north.

Once again I believe that this is due to the superiority of the climate rather than the medical services. Here we see percentage surviving for five years.

There is a lot of sun in Italy. Rome receives sunlight energy at ground level of 176W/m2, compared to 109 in London, and even lower at 94 W/m2 in Edinburgh. The only city recorded with lower sunlight energy is Anchorage, Alaska, at 79 W/m2.

This is the key to the success of Italian health statistics. The UK government cannot control the sun. It is clear that medical efforts to mimic the results of Italy, at great cost, have not been successful. It is time to acknowledge the importance of climate - the sun - and perhaps to encourage exposure to the sun, UV light and vitamin D to try to improve the health and life expectancy of the British people.

While we are on the subject of Italy, you might care to look at a couple of short movies that I prepared following a short trip to Modena to see if it looked different from anywhere else. The clear blue sky made it obvious that I was not at home in north-west England! The movies are from nearby Ravenna and Classe, famous for the wonderful mosaics created by the Visigoths in their capital city at the time.


Ravenna Basilica St Vitale Italy

Tuesday 3 September 2013

The benefits of Vitamin D and the Sun

The usual way to demonstrate a health benefit, or disadvantage, is to start with an observational study. This entails identifying the characteristic under investigation  in a large sample of the population and then observing the outcome after a good number of years. This is inevitably a long process.

If we are interested in vitamin D then a blood sample will need to be taken at the beginning of the study and either tested then or frozen and stored for analysis at the end of the study.

Ultimate outcome measures are obviously very important and accuracy is paramount. There must be access to the subjects and their health records, despite any movement they might make. The major illnesses that they encounter must be recorded, usually by annual contact with each subject. And then of course their deaths must be noted and the causes of those deaths must be identified. This becomes possible with good national records, better in some countries than in others.

The progress of a large group of individuals has been followed up in the USA and deaths rates have ultimately been determined. Vitamin D status was identified at the onset of the study. The deaths have been grouped into Cancer Deaths, Heart Deaths, Infection Deaths, and All-cause Deaths.

The inclusion of all-causes deaths is of critical importance. Something might cause an excess deaths and therefore will inevitably bring about a reduction of deaths from something else. For example war will cause trauma deaths but a reduction of heart deaths. A reduction of all-cause deaths is thus the critical starting point, and it is of course most important to us all.

Relative mortality rates

We can see the four groupings of the subjects on the basis of blood levels of vitamin D. The lowest group had levels less than 18ng/ml (less than 45nmol/L), shown in the lightest columns. This is actually the average level of about 3000 subjects who I have investigated in Blackburn, UK. The average in this study was 24 (60). The highest levels were grouped as greater than 30ng/ml (greater than 75nmol/L), shown in the darkest columns, and this brings us into the ideal range with present understanding.

If we look at "All-causes" mortality, we can see that those with the highest vitamin D levels are standardised on 1, and also with the other categories of death. The other vitamin D groupings have mortality expressed as relative to this. For all-causes deaths, the relative death rate progressively increases as vitamin D levels diminish. In the group with the lowest vitamin D levels the mortality rate at 10 years was almost twice that in the group with the highest levels.

We see a similar effect in deaths from cardiovascular disease, cancers, and infectious disease, but all-cause mortality shows the greatest variation indicating that vitamin D gives a wide range of health advantages, not something that is found in just a single disease or cause of death.

So someone with a blood level of vitamin D greater than 30ng/ml (75nmol/L) can be reasonably assured for the future, although cannot be expect immortality!

But the important thing is to identify those with the lowest levels as they are much more at risk. The study only allows us to see low levels as less than 18ng/ml (45nmol/L). Would there be any difference between people with blood level of 15 (37) and those with blood level of only 5 (12)? We do not know but the results shown indicate a gradual and progressive increase in risk with reducing vitamin D level. It is remarkable how many people have such a profoundly low blood level of vitamin D, mainly but not exclusively South Asian people living in the UK.

If we wish to improve the health and life expectancy of those with the lowest blood levels of vitamin D it seems to be reasonable to give them a supplement, usually about 2,000 units per day or equivalent by mouth. Although this is now undertaken on quite a wide scale, it has not yet been demonstrated that it will be of benefit. There should ideally be a long term clinical trial, only half of those found to be deficient of vitamin D being given the supplement. This is not likely to happen as firstly it would be very expensive to conduct, and secondly would anyone give informed consent to receive a dummy tablet if known to be vitamin D deficient?

We need to remember that the sun has two metabolic effects on the skin. The first and most well-known effect is the production of vitamin D. The other effect, only recently identified, is the production of nitric oxide, which seems to have at least benefits on cardiovascular health. There might be more to vitamin D deficiency that an supplement and there might be no full substitute for the sun.


Melamed ML, Michos ED, Post W, Astor B.25-Hydroxyvitamin D levels and the risk of mortality in the general population.Arch Int Med 2008; 168: 1629-1637.