Friday, 19 March 2021

Covid-19 & Vitamin D : do not sit on the fence when there is blood on the floor

Covid-19 & Vitamin D

No sitting on the fence: there is blood on the floor!

2008. I just managed to get out of the way !

When the pandemic of Covid-19 appeared a year ago there was a great deal of evidence predicting that our known widespread deficiency of vitamin D would cause a serious problem. It would produce a problem of sub-optimal immunity, and thus a high risk of death from critical or fatal infection. And this is what happened. As expected the deaths occurred in excess in communities known to have a high prevalence of vitamin D deficiency: the ethnic Black African and Asian (BAME), the obese, and the elderly in particular. 

The early missed opportunity

There could have been community-based blood testing to detect individuals with vitamin D deficiency, but it did not happen and vitamin D testing was discouraged by public health bodies. Vitamin D could have been given to all, on the basis that in a single dose of 100,000 units it would have corrected deficiency of those deficient and would have done no harm to those not deficient. Blood testing within the following three months would identify the need to continue with a supplement. Alternatively a vitamin D supplement dose of 20,000 units each week or 3,000 units each day would have been appropriate and perfectly safe.

But official correction of vitamin D deficiency did not happen. We had to wait for more than 100,000 deaths before vaccines became available. 

We have had a large number of "scientists" who have dominated the political agenda. There have been mathematicians, statisticians, epidemiologists, virologists, nutritionalists, sociologists, the chief medical officer and the chief scientists, both of who have enjoyed an academic career. Some of them have mentioned vitamin D with a remarkable lack of enthusiasm, in complete contrast to their embrace of vaccines.

The dead hand of NICE

The reason for the denial of use of vitamin D has never been clear. The large amount of evidence from the forty years preceding the pandemic made little difference to official advice. Reference was always made to the reports by NICE, the National Institute for Health and Care Excellence. 

The reason why the correction of a vitamin deficiency had to be referred to NICE is difficult to understand, as it would be an automatic clinical duty to correct a vitamin or hormone deficiency, be it vitamin D, vitamin C, vitamin B12, the prescription of insulin or thyroxine and so on. But NICE has somehow been given the responsibility for the correction of vitamin D deficiency, and a series of its reports failed to approve the use of vitamin D, but always failing to acknowledge deficiency. 

NICE informed the nation of a lack of evidence and demanded randomised controlled clinical trials (RCTs). 

A report from NICE on June 29th told us that:

"There is no evidence to support taking vitamin D supplements to specifically prevent or treat Covid-19" 

This avoided any mention of the fact that research points to the majority of the population being deficient of vitamin D. If NICE is supposed to help doctors in their treatment of ill patients, it failed miserably to do so. The response has been very far from Excellent.

Once again more evidence, randomised controls were demanded. The result of the first RCT, from Córdoba, Spain, appeared on September 3rd. The response of NICE was that the (very positive) result should have no influence on the way in which doctors treat patients (with Covid-19 pneumonia). 

"The clinical management of patients with COVID-19 should not be changed based on the results of this study."

On December 18th NICE published a joint report with SACN (Scientific Advisory Group on Nutrition) and PHE (Public Health England) in which Sir Paul Chrisp (director of the centre for guidelines at NICE) stated:


"While there is insufficient evidence to recommend vitamin D for the prevention or treatment of Covid-19 at this time, we encourage people to follow government advice on taking the supplement thought the autumn and winter period."


The reason for this change of direction is that the Health Secretary Matt Hancock had stepped outside NICE advice. He had become aware of the importance of vitamin D in the prevention of Covid-19 and he issued a directive that all elderly people should be issued with a vitamin D supplement. NICE could not disagree with a minister and so it had to use double-speak, taking advantage of the many synonyms in the English language. To "recommend" and to "encourage" are verbs without an obvious difference in meaning.


NICE cannot be regarded as having the best interests of the sick and dying at heart.


NICE denies responsibility


The full NICE report that included the first RCT of vitamin D as 25(OH)D or calcifediol, its natural rapidly-acting form, appeared in December 2020. Although the earlier report carried its "recommendation" that doctors should not have their treatment of patients be influenced by this first RCT, the full report carried an interesting disclaimer:


"The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian."


NICE and other documents carried generally very negative reviews of vitamin D, and denied the role of vitamin D in defensive immunity, ignoring the accumulated evidence. It has been the same in other commentaries, at best balanced, always stating a need for more research, but when is there not a need for more research? Does science ever stand still? Is a balanced view of help to a doctor caring for the sick and dying?

There was undue publicity given to two barely comprehensible papers that were pre-published in January 2021. 



One was from Canada, the other was from Greece.They stated that there was no evidence of benefit from vitamin D. They were of very poor quality and added nothing, but headlines were dramatic.

The very positive result of the second controlled trial, from Barcelona, has received no official comment. It was "rejected" by Professor Adrian Martineau, a member of NICE. Still a demand for more RCTs that would inevitably necessitate more human sacrifice.

No evidence?

The common suggestion of "no evidence" is absurd. Let us assume that there had been a murder and that ten detectives were sent out to investigate. On the following day eight detective returned to HQ and reported that they had all found incriminating evidence that pointed to one man who appeared to be guilty of the crime. On the following day the other two detectives returned and stated that there was no evidence of the accused man being responsible for the crime. Would their finding of "no evidence", or rather their failure to find evidence, invalidate the evidence found by the others? 

Of course there is ample evidence to suggest that vitamin D would be of benefit in Covid-19, but most people seem to be unaware of it.

A view from an ivory tower

A recent editorial in the British Medical Journal on the subject of Covid-19 and vitamin D was written by two nutritionalists and a professor of primary care diabetes, the latter having previously written what I can only describe as a non-medical appraisal of the high Covid-19 death rate of BAME people without once mentioning vitamin D! Even though it was in the British Medical Journal, the editorial was of no practical value to practising doctors. There was no practical advice as to how to reduce the deaths from Covid-19 in any ethnic groups. 

"Existing evidence supports a compelling case for further research." Let's just kick the can down the road while more people die. 

The authors of this editorial, like perhaps all commentators on the subject of Covid-19 and vitamin D, did not have responsibility for patients admitted to hospital with Covid-19 pneumonia. Whether or not they themselves took vitamin D was not declared. They gave no advice as to whether such patients should be treated with calcifediol as in the Córdoba protocol, but they gave ample discouragement. 

Advisors to government but not to doctors

Government advisors on the Covid-19 pandemic live in offices, ivory towers. They do not live in the emergency areas of hospitals. They never see blood on the floor. They do not know what it is like to make life or death decisions. They do not understand the pressure to do the very best to help an individual patient. But they inhibit rather than help those front-line doctors who need support.


A report in December 2020 from an all-party committee of parliament also managed to find no place for vitamin D. The ignorance is wide-spread.


MD in Private Eye is not one to follow central directives, but his first and very brief mention of vitamin D during the pandemic informed us that "The jury is still out". He followed this by a plea to be given vitamin D should he develop Covid-19 (Eye 1452). If the jury is still out it indicates that evidence has been withheld or that the judge has failed to give direction. However MD showed some of the pragmatism that doctors require, but in advice to others he followed the official line: he clearly sat on the fence of indecision.




Clinical decisions

For a clinical doctor to make a decision to prescribe vitamin D / calcifediol for a patient with Covid-19 pneumonia is actually very straightforward and I am sure that non-one would argue with it. Surely a doctor would not regard herself or himself of being at risk of charges of negligence or other disciplinary charge should vitamin D be prescribed. But doctors are frightened of giving vitamin D. 

Decision-making is encapsulated in Pascal's Wager, that I have described previously.

To give vitamin D as calcifediol to a patient admitted to hospital with Covid-19 pneumonia would have a high probability (about 70%, but not certainty) of reducing the need for ICU transfer and death, and it would have a cost of about £10, with no side-effects. 
To deny the patient calcifediol would correspondingly fail to reduce the need for ICU transfer and failed to reduce the number of deaths.

What could be a more simple decision than this? Obviously vitamin D / calcifediol must be given, that is if the objective of the doctor is to minimise illness and reduce the chance of the death of a patient. Can anyone provide a reason why a patient critically ill with Covid-19 pneumonia should not be treated with calcifediol, or why anyone deficient in vitamin D not have the deficiency corrected?

Why is calcifediol not being given to patients with Covid-19 pneumonia in the UK? Because NICE says that it should not be given. Doctors and their managers are frightened of not obeying NICE. Can NICE justify it actions in denying vitamin D to those are dying?

Legal claims

It has just emerged that there is a now a group legal claim against the UK government as to why not more was done to protect the population, so as to keep the number of deaths well below 125,000. 



The legal claim is bound to uncover the fact that vitamin D and its active metabolite calcifediol (25(OH)D) had been withheld, when all the evidence pointed to it being very helpful and life-saving. 83,000 people have died since the result of the Córdoba study became available on September 3rd, and a significant number of these deaths were therefore avoidable. The question in a court of law would be, "Why was vitamin D not given?" The government will point out that it was only following the advice given by NICE. NICE will defend itself by pointing out its disclaimer, which I will repeat as it is vitally important in its defence. The disclaimer must have been written by lawyers.

"The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian."


Who will be held guilty?

This declaration clearly shifts the blame for the deaths of patients to hospital doctors, for following its repeated advice!

This is a disgrace.

The responses of doctors and their professional organisations, and the General Medical Council will be interesting.





 










Monday, 8 March 2021

Covid-19 & Vitamin D – Haredi, BAME, Obese, Elderly at risk



Covid-19 & Vitamin D – medical ignorance continues and we are failing to help the vulnerable

Haredi Jewish community

BAME, Obesity, Haredi Jews, Elderly: 

more excess deaths 

There is much denial of the importance of vitamin D in human health, and especially during the present pandemic of Covid-19. So much has been learned, or at least should have been learned from recent experience, and a pandemic such as this brings a great deal of information to widespread attention. Many features of the health of the population come together to produce a picture that is much more clear than in the past. The life and death occurrences become understandable but only if we base them on the scientific progress that has occurred during the past forty years. However, knowledge of this appears to have been missed by most doctors, and the key points remain unclear to the majority.

I have explained previously that vitamin D first appeared two billion years ago. Early sea life, plankton, was able to produce the oil 7-dehydrocholesterol, which UV from the sun converts into vitamin D. 500 million years ago, the more complex life-forms that had evolved fed on the plankton, and it came to pass that they consumed vitamin D which was able to activate the intracellular protein that we now know as Vitamin D Receptor (VDR). This led to the very complex but brilliantly effective cascade of defensive immunity. How this all happened during evolution is far from clear, but it did happen.

Most people know about rickets, "bendy bones" that cause skeletal deformities, widespread during the late industrial revolution. It seems to have been forgotten that this was the result of atmospheric pollution blocking the penetration of sunlight to ground level. 

Atmospheric pollution in England 1950

Atmospheric pollution in India 2020

Deficiency of what later became identified as vitamin D was the reason for the development of rickets, and following its isolation initially from fish oil, rickets could easily be treated. 



Skeletal deformity typical of rickets


When vitamin D was first isolated, it could not be measured by chemical means, but it was measured by its biological activity. One unit of vitamin D was defined as the daily requirement of a 10g immature mouse. It appears that this is generally not known, but to scale up from this the daily requirement for a 60kg human being would be 6,000 units per day, and for a 120kg obese person 12,000 units per day. In that adult humans of these weights are "mature", it would be sensible to take halves, 3,000 units per day for normal weight and 6,000 units per day for the obese. 

SACN, the UK scientific advisory committee for nutrition, appears to be unaware of the pivotal role of vitamin D in defensive immunity and tells us that all we need is 400 units per day. This is the equivalent to a mouse taking 0.07 units per day, but it appears to be adequate to reverse rickets in a human child. It is the importance of the immune function of vitamin D that, during the pandemic, has become crystal clear to those who are not asleep.

"Sunshine Clinic" 1961

By the middle of the 20th century the use of Cod Liver Oil and also "sunshine clinics" for children led to rickets becoming extremely rare. With the controls of atmosphere pollution the use of fish oils declined and sunshine clinics were closed. During the second half of the 20th century it became possible for vitamin D in the blood to be measured by physical-chemical means, initially as a research tool and then in standard clinical practice.

It became clear that although rickets was rare, vitamin D deficiency as defined by a blood test was common, especially in certain groups of the population. The importance of this has not been clear until recently and it has been necessary to refine the definition of vitamin D deficiency.


Black African and Asian Minority Ethnic people (BAME)

The second half of the 20th century in the UK had seen immigration of many people from the Commonwealth, especially from India, Pakistan, several nations of Africa, and the islands in the Caribbean. During the 1960s and thereafter cases of rickets appeared in the children of these immigrants, and also tuberculosis among the adults. Later, it was noticed that the incidences of coronary heart disease and diabetes were also greater. Underlying this was the development of vitamin D deficiency with movement from the tropics to more than 50 degrees north of the equator.

The extent and severity of vitamin D deficiency can be seen in the bar chart, each vertical black line representing one of the 1754 ethnic South Asian subjects who I investigated about 20 years ago. 



Very few had a blood vitamin D level in the "safe" range above the red line, greater than 30ng/ml (75nmol/L), and only 4 had a blood level in the ideal range (40–60ng/ml (100–150nmol/L). The median average was 9ng/ml (22.5nmol/L). More than half were seriously deficient. In a comparable group of 865 ethnic white people, the median average was 18ng/ml (45nmol/L).

Vitamin D deficiency is very common in ethnic South Asian people and it is still not being appreciated. Public health has much to learn.

The Covid-19 pandemic has seen a particularly high mortality rate among BAME people, those of Black African and Asian ethnicity. This was serious and brought about three "detailed" investigations, but not detailed enough. The three reports concluded that social deprivation and racism were the reason for the excess deaths. The medically well-known and easily reversible deficiency of vitamin D was not considered. Medical leaders remained silent and an important opportunity to minimise deaths was missed.

Comment on the Report by Dame Doreen Lawrence


December 2020 saw the publication of an Interim Report of the UK All Party Parliamentary Group on Coronavirus. In its 90 pages there was not a single mention of vitamin D, but this is perhaps not surprising as parliament is noted for its lack of scientific understanding. The report indicated that compared to the national average, there has been a four times higher Covid-19 mortality of ethnic Black Africans and three times higher for ethnic Asians. No explanation was offered.

Racism and socio-economic disadvantage of BAME people were also the conclusion of a BBC television programme on March 2nd 2021. Vitamin D was mentioned, only to be rapidly dismissed. It was as though fifty years of clinical medicine had been forgotten, and forty years of biomedical research had never happened. In fact it appeared that there had been a complete failure to learn from medical experience during the past year.   

BBC television programme on March 2nd that also missed the opportunity

It was acknowledged that not just the poor BAME experienced excess deaths from Covid-19, but also BAME doctors. The vitally important fact that of 25 working doctors who died form Covid-19, 24 were BAME was not mentioned. The 24 deaths were in vain and lessons were not learned.

"It could not be skin colour that caused excess deaths because Black people in Africa have very low death rates". 

An unbelievably ridiculous deduction, completely ignoring the interaction between genetics and environment (sickle cell disease is another example of this, advantageous in the tropics where there is malaria, but a great disadvantage when living in the UK). 

It also ignores the effect of transmigration, and the evolutionary selection of white-skinned people to live distant from the equator, where sunlight intensity is low. For this to come from a doctor shows staggering ignorance, of which those responsible for medical education should be ashamed. The truth is that BAME people have moved from the tropics to a country that is closer to the North Pole than to the Equator. The diminution of sun exposure and vitamin D production is responsible for the excess deaths, the melanin-rich skin blocking UV and making vitamin D production very inefficient. 

The vitamin D deficiency of BAME people was ignored yet again. It is the most if not the only biologically plausible explanation of the excess deaths, not only from Covid-19 but from several others causes of early death. At a time of crisis with more than 120,000 deaths, it would be sensible to correct vitamin D deficiency immediately rather than waiting to correct low income, low quality housing, inner city living, and racism in all walks of life, none of which could be achieved before the premature deaths of many more people.

It would have been so simple to correct widespread vitamin deficiency in the BAME groups but it did not happen. Was this the result of ignorance by medical scientific advisors, or was it wilful ignoring? Could the ignoring be called racism?


Obesity and vaccine failure

It has been reported from research in Rome that in the obese the vaccines produce only half the antibody response that would be expected. The reasons for this were explored but without any consideration of vitamin D.


This headline is not really surprising. An ideal blood level of vitamin D as 25(OH)D, calcifediol, is essential for the immune response that is necessary for the success of vaccination. It was predictable that the success of vaccination would be diminished in the obese. This is one of the groups with a high risk of death from Covid-19.

It is well-established that the obese have a high incidence of vitamin D deficiency. When vitamin D as cholecalciferol is produced in the skin or taken by mouth, it is taken to the liver, where the slow conversion to 25(OH)D calcifediol takes place. This is much slower in the obese and much vitamin D is deposited in fat cells. Following exposure to UV, the important 25(OH)D appears in the blood only slowly and inadequately in the obese. Strictly speaking, the low blood levels of vitamin D in the obese is an expression of reduced bio-availability rather than absolute deficiency, much of the vitamin D being in the fat cells and unavailable to the blood and for metabolic use.

It has also been observed in the recent past that vaccination against hepatitis B virus has a high failure rate in the presence of vitamin D deficiency.

It would have been sensible to use vitamin D and vaccination together, vitamin D being given perhaps a month before the vaccine.

Center for Disease Control, USA

Reducing obesity is a good thing but experience tells us that it is slow and difficult. The neglect of the immediate correction of vitamin D deficiency in the obese has led to many avoidable deaths.


Headline from March 4th 2021. It should been in 2020.

The obese might be given priority for vaccines, but had they been given priority for vitamin D a year ago, many deaths would have been avoided.


Haredi Jews

This small group of UK citizens has had a particularly high death rate from Covid-19. The group comprises only 260,000 people who live in a small number of close-knit communities with little integration with general society. Although unmistakable from their dress, they are mainly unseen within the nation and so their high Covid-19 death rate has not been noticed. There are ten times more Moslem people in the UK and their high death rate is much more obvious.

Recently headlines have appeared in the UK from the BBC and in the Guardian.





The same has been reported concerning the ultra-orthodox Jews in Israel. 

The Times of Israel, March 4th 2021


Observation of the Haredi Jews in the UK will lead to a suspicion, or perhaps a glaringly obvious certainty that they are vitamin D deficient. They dress with traditional extreme modesty, which together with the extensive facial hair of the men and large-brimmed hats would minimise exposure of the skin to the sun, even in the summer. The women expose only their hands and face. 

And so it is. Investigation in Israel has confirmed the suspicion of vitamin D deficiency among the ultra-orthodox

A report from Israel in 2001 concerned the investigation of Jewish mothers, blood for vitamin D being analysed within three days following child-birth. Some of the women had been taking a vitamin D supplement during pregnancy, but just in the minimal dose of 400 units daily. For the purpose of analysis the mothers were divided into the orthodox and the non-orthodox. 

Israel is a land with plenty of sunlight, but being outside the tropics it has a winter and a summer. However vitamin D deficiency was disturbingly common. We need to remember that experience during the pandemic of Covid-19 has demonstrated that a blood level above 30ng/ml (75nmol/L) is safe with minimal risk of critical or fatal disease, and within the range of 40–60ng/ml (100–150nmol/L) is ideal. But in the Israel study the mothers were classified as "deficient" if the level was less than 5ng/ml, and "insufficient" if less than 10ng/ml. These levels were very low, and less than 5ng/ml could give rise to rickets in the offspring. Less than 10ng/ml (25nmol/L) is generally regarded as serious vitamin D deficiency.

The results of the study are shown in the bar-chart.




We can 
see that one quarter of the non-orthodox mothers had blood vitamin D levels less than 10ng/ml, fewer in those who had received a vitamin D supplement during pregnancy. We were not informed of the blood levels achieved by taking the supplement.

Half of the orthodox Jewish mothers had blood vitamin D levels less than 10ng/ml. This was helped but incompletely by the vitamin D supplement, 400 units daily.


A summer day in Israel

Here we see a photograph of two orthodox Haredi couples in Israel. This was taken at midday in mid-summer, as indicated by the very small shadows. The men's faces are shaded by their hat brims and their hands are in their pockets. It can be appreciated why the blood levels of vitamin D in the orthodox Jews are very low, and that of the mothers did not show any increase in the summer, whereas there was an increase in the non-orthodox.  

With the prevalence and severity of vitamin D in Haredi people in Israel, we can only expect the deficiency to be the same or even worse in those living in the UK. The research that I have demonstrated was in Israel twenty years ago. Why does it appear to be unknown? Why has the susceptibility of the Haredi people in the UK been officially "explained" by socio-economic factors, even when this has been eliminated in comparison with Christian men in London.

                              

Knowing of the importance of vitamin D in defensive immunity and the susceptibility of those deficient to critical and fatal Covid-19, it would have been very simple to investigate  deficiency of vitamin D among the Haredi groups in the UK. But this simple study was not undertaken. Medical scientists (other than those developing vaccines) are asleep and so the expected vitamin D deficiency was never confirmed and of course never corrected.

We can hardly expect the Haredi Jews to change their traditional dress and lifestyle, but to have corrected vitamin D deficiency would have prevented many deaths. Our failure to do so is the result of medical ignorance, that I hope experience during the Covid-19 pandemic will correct.


The elderly

Headline, May 14th 2020

We have watched the large number of Covid-19 deaths among the elderly, whist knowing of the importance of vitamin D in defensive immunity, and also knowing of the inability of the skin of the elderly to produce vitamin D. This was first demonstrated in 1980. 

The skin produces the oil 7-dehydrocholesterol (7-DHC) and  UV from the sun acts on it and converts it into vitamin D. But the thin dry skin of the elderly produces only small amounts of 7-DHC and therefore vitamin D production in the skin is inadequate all the year round. Deficiency is inevitable and all elderly people require a supplement by mouth; the sun will not help.

Vitamin D production in the skin, young and elderly

But what has been done? There has been advice for the elderly to take vitamin D 400 units daily, the requirement to prevent rickets in a child, but not to restore blood levels that will optimise defensive immunity at the time of serious infection. 


Four neglected groups

We have seen that as a nation we have ignored the medical scientific knowledge of the past forty years, and we have neglected the welfare of four important groups of our population, the obese, those with ethnic melanin-rich skin that is inefficient at producing vitamin D when living at 54 degrees north of the equator, the Haredi Jews who have minimal exposure to the sun all the year round, and our elderly who are unable to produce vitamin D.

Vaccines are now being used extensively to provide immunological protection of the population, but there are concerns about the protective value of vaccines against a wide range of mutations of Covid-19. These fears might be unfounded but there is inevitably uncertainty about the future. 

However it should be realised that vaccine success depends on the optimal immune process that is determined by adequate vitamin D. It must also be remembered that optimal immunity is successful against all viruses and all mutations.

It is not a question of vitamin D or vaccines, it is vitamin D and vaccines. But vitamin D should be given first, and that should have been one year ago when the pandemic emerged.

It is important to learn, not just from the past forty years of research into vitamin D and defensive immunity, but especially from the great experience generated during the pandemic of Covid-19. But we must be prepared to learn and not deny new knowledge.  




https://www.ypdbooks.com/2147-vitamin-d-deficiency-and-covid-19-its-central-role-in-a-world-pandemic-YPD02419.html