|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.
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.
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.
|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.