Episode #381: How a Supplement Sent a Soldier to the Hospital- A Medical Mystery

25:09And then not really, fortunately, a ton else, 23-year-olds can be pretty robust and resilient even after going through something as dramatic as this. He seems to have mostly recovered based on the trajectory that you told me so far. Yeah. All right. Well, let's talk about this jaw pain for a second, because I was wondering about it. I'm sure you're wondering about it, the audience probably wondering why. To me, this is fascinating. So tell me what you think about this potential mechanism. So we know that excess vitamin D doesn't just increase calcium absorption from the gut. It can actually drive some level of bone resorption.

25:40We usually think of vitamin D as a good thing, but in extreme amounts, it can cause the body to aggressively pull calcium out of the bones and into the bloodstream. So this could explain the jaw pain, not like a dental problem, but rather the physical sensation of his body stealing calcium from his own skeleton, including his jaw, to dump it into the blood. So I looked into this a little bit regarding the jaw specifically. Bone resorption is systemic, but the jaw is a site of very high bone turnover sort of normally. So in cases of extreme bone resorption, which we see in hyperparathyroidism or severe vitamin D toxicity like this patient, people can develop what are called brown tumors or focal areas of bone loss.

26:21And so it's possible that this agonizing pain he felt was his own bone structure being chemically dismantled from the inside out, potentially causing microfractures that were missed on routine imaging and changes in the local bone marrow environment from the rapid bone turnover. So I went into like a radiology rabbit hole. I'm like, how often does standard like x-rays miss this? And quite frequently. The vomital exposure. It's been going on for a long time and it's very severe. So it would have been interesting if he got some either advanced imaging or some sort of like radiolabeled imaging to suss this out.

26:52But I don't know. What do you think about that mechanism? Yeah. So you're right that the jaw seems to be an area of more aggressive turnover. And that's why, for example, when patients are put on certain treatments for osteoporosis like bisphosphonates. We often tend to be a little bit cautious, especially if they have dental work, pendank, things like that. There's phenomenon called osteonecrosis of the jaw that can happen in those patients where there's some bone that actually dies in the jaw related to the use of those medicines. So we tend to be pretty cautious around that. I haven't heard of this happening from vitamin D toxicity, but if it is accelerating bone turnover, I find that a plausible mechanism.

27:26I also am completely unsurprised that just like routine x-rays of the jaw, especially if these are just like routine ER x-rays. And this is not shade at the ER, but rather that those types of x-rays are done, you know, pretty quickly. Sometimes even like, you know, a lot of ER x-rays are done portable at the bedside and being read, looking for major emergencies by emergency radiologists. And so the really detailed nuances, I wouldn't be surprised if those don't always get caught, or if you need some more type bone scan or some sort of like, you know, imaging that looks for kind of cell activity in the area, some sort of nuclear medicine.

28:02You know, this is outside getting outside my area of expertise. And in practice, I frequently just get on the phone with a radiologist and I'm like, hey, here's what I'm thinking. Here's what I'm worried about. What's the best scan for me to, you know, to look for this particular issue? And that's what I would be have been doing in this situation to try to figure it out if the plain x-rays were unrevealing, which is, again, not at all surprising to me. So I find that to be plausible, interesting. we know the jaw is a hotbed of bone activity and relates to a lot of these conditions. This podcast is brought to you by Biggs.

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29:39One study that gets a lot of airtime, it's been cited a bunch, is this PILS study from 2011. I've seen it actually cited a few times online in the biohacker and sort of natural testosterone optimization circles. It suggested a link between vitamin D supplementation and testosterone. Now, in the study, a group taking about 3 ,300 IUs of vitamin D per day for a year increased their testosterone levels from an average of 300 nanograms per deciliter to 380 nanograms per deciliter, whereas those taking a placebo didn't see any changes. So you look at that and you're like, that's a bump. I want a bump.

30:16More testosterone, more gains. There are a few problems with this study. So one, it was not actually designed to test testosterone levels. It was actually a secondary post hoc analysis of a weight loss study. The researchers didn't recruit men to see if vitamin D built muscle or increased testosterone. They just looked back at a small group of 54 dudes who happened to have their testosterone levels measured. Now, in the world of science, when you dig through enough data after a study is already over, you can typically find a correlation with something by sheer coincidence if you look at enough variables.

30:48No shade intended, but this is a classic case of data mining being presented as a primary discovery. This happens all the time, unfortunately. The second problem with the study, again, we're talking about 54 people. In a study that small, one or two outliers can completely skew the average. The difference was modest, 300 to 380 nanograms per deciliter, so not crazy. So tiny sample size, the statistical signal can be incredibly noisy there. This is why larger, better-controlled trials and meta-analyses with hundreds of thousands of patients can be better at showing the real relationship. The other problem here is that they used an immunoassay to measure testosterone levels, which is an older type of test that is notoriously unreliable, especially at lower testosterone levels, compared to the new tests we use, which are LC-MS.

31:37And then finally, even if we take the study at face value, the increase they found is almost certainly not clinically significant. This slight bump in numbers, which are, they're well within the test's error bars, and the study did not measure, like, muscle protein synthesis. It didn't measure one-rep max strength or muscular hypertrophy, body composition, or even symptoms of testosterone deficiency. So like a slightly higher number on a lab report, to me, doesn't matter if it doesn't actually change the person's life. We see this all the time. People will take this tiny shift in a surrogate marker, and then, especially with a supplement, and they'll just run with it, market it to the hills.

32:14Now, three recent meta-analyses essentially closed the door on this. They looked at the totality of the evidence and found that vitamin D is pretty much a total wash for testosterone levels, regardless if someone has low or normal testosterone levels or low or normal vitamin D levels. So the analogy I think about here is like, if you take vitamin D to boost testosterone, it's kind of like trying to fix a car that won't start by adding more gas to the tank. If the engine is the problem, it doesn't matter if your gas tank was bone dry or already half full, adding more fuel is not gonna make the car run.

32:49You can keep pumping more and more gas, that's the vitamin D, but you're not fixing the motor. That's the source of the testosterone deficiency. You're just creating potentially a massive spill that could become a fire hazard or, in our patient's case, metastatic calcium deposition. So, Austin, we have this massive industry built on the idea that more is better and that vitamins are typically benign. Walk us through why vitamin D is different from water-soluble vitamins like vitamin C or vitamin B12. And why do you think that natural testosterone marketing, that that machine clings to stuff like this?

33:23Yeah, lots of reasons. It's certainly a hot topic these days, even though we've been talking about testosterone for many, many years at this point. So to the first question, the concept of fat-soluble vitamins is, you know, it has to do with the type of solution that they dissolve best into, whether it's fat or our water-based bloodstream. And water-soluble vitamins tend to last for a shorter period of time in the body and can get readily excreted in the urine as a water-based kind of medium. The fat-soluble vitamins tend to get sequestered in our adipose, in our body fat, and they can sit there for a long time.

33:59They are not easily excreted in the urine because we are excreting water and not kind of a fatty—we don't pee out oil as a way to excrete that. That would be a problem. And so the trade-offs there are that if somebody is completely deficient in—say their diet is completely deficient in water-soluble vitamins, they are more readily going to become deficient in that on a shorter timeframe because the intake and output happens on a shorter basis. Whereas the fat-soluble vitamins that can accumulate and get sequestered, you're going to be a little bit more resistant to developing deficiencies if you have some stores built up in your body fat.

34:39The trade-off there is that if you get toxic, if you have too much of it, then it can accumulate and you can have prolonged toxicity. instead of if somebody overdoses on thiamine, I'm not concerned at all. In fact, I probably intentionally overdose people on thiamine in the hospital all the time because the risks of being deficient in thiamine are so great, whereas the risks of me giving them way too much are essentially zero. And so I err on the side of treating people very aggressively with thiamine when they're at risk for deficiency, if they have alcohol use issues, things like that. But I don't at all do that with vitamin D.

35:12There's no situation where I'm aggressively giving somebody vitamins A or D or E or K, being the predominant kind of fat-soluble vitamins outside of very, very, very rare types of situations. And so that's the fundamental difference and one that played out in this patient's case. I totally get, you know, when people perceive a problem or if, in fact, they do have a problem like testosterone deficiency, trying to seek out what basic measures, be it lifestyle, quote-unquote natural, or otherwise can I do to try to improve this. And I don't even fault people who might say, look, I understand what you're saying that 80 nanograms is not a clinically significant difference.

35:50But maybe if I do this to get 80 and I stack it with sleeping better and that gets me 50 and I lose a little bit of weight and that gets me 100, maybe that takes me from 300 to 500 or 600. And the accumulating effect of multiple small interventions or something like that. I'm like, okay. I mean, it sounds like we're pursuing a generally, we're aiming to pursue generally healthy lifestyle pattern, trying to tinker with a lot of small variables and hoping that that adds up to a generalized improved downstream state of health. I think that that's not a crazy idea, but of course, this is also being done like as seen in this case without a good understanding of what are the potential downsides of things like dosage and monitoring and how I'm actually going about this process, right?

36:29And so to those meta-analyses, I'm not surprised that it ended up coming out in the wash. There's also some questions of how much does it matter kind of how you got there type picture, right? So if somebody had a vitamin D level of zero, I wouldn't be surprised if maybe having some vitamin D replacement leads to improvements in various other things. But of course, at the same time, my question is like, what led to their vitamin D level being zero? Are they just frankly, completely malnourished for some reason? Do they have some undiagnosed, you know, GI pancreatic intestinal disease that leads them to be unable to absorb certain nutrients altogether.

37:04And it's not as simple as just, oh, just give them the vitamin D and then it'll fix their testosterone. But maybe a whole bunch of systems can be made to function better if we identify the underlying issue here, right? And the same if somebody's testosterone level is, you know, zero, that's actually the lowest I've ever seen is the testosterone levels. Yeah, okay, it's not going to be like take vitamin D and get your level from zero to 80. And it's like, why did it get there? So that's part of why when we talk about testosterone deficiency, we talk a lot about the importance of accurate diagnosis, a proper medical assessment to think through what sorts of things could be contributing, what sort of levers can we pull, and how hard should we pull those things?

37:42Is there a scenario where I might tell somebody, yeah, we should probably put you on some vitamin D? Yeah, I can see that happening. But that is not really very common for me to say, oh, your testosterone is like mildly low. Let's just get you on some vitamin D and it should fix your testosterone levels. This is more like severe deficiency to help address a lot of issues while I try to get to the bottom of like, why did any of this happen? Right? So it's really interesting hearing myself say this because I recognize how often out there there is this view of, yeah, doctors just treat symptoms. They don't look for quote unquote root causes.

38:16Meanwhile, here I am saying, hey, I'm curious why we ended up in this state of testosterone deficiency, of severe vitamin D deficiency, et cetera. And I'd rather figure that out and address those things. Whereas a lot of folks in this kind of biohacker optimization space, they're like not really terribly curious about how those things happen, but they rather just like take the zinc and the boron and the vitamin D and, and the, and the, you know, the cert, the SARMs or whatever, whatever that kind of stuff, um, to, to make the numbers look prettier. It's almost like a total inversion of that same perspective when applied in other contexts.

38:49Yeah. Yeah, no, that's a, that's a good summary. And we know that like lifestyle and general health status play a significant role in both vitamin D levels and testosterone levels. So it's no surprise to me that there's a correlation between the two being low. For example, an individual with, uh, excess body fat, uh, not sleeping well, maybe their dietary pattern is, is not as good as we want it to be. It's no surprise to me that these things trend together and that if you improve somebody's health, that both things will trend back the other way. The real question that we're getting at here is, does independent of all of that, adding a vitamin D supplement actually help?

39:27I know it'll make the number, the vitamin D number look better, but I have a low pretest probability that doing it will independently raise testosterone levels unless other stuff changes. totally and yeah and and certainly like to what we would deem a clinically significant degree it's not taking it's very unlikely absent a whole bunch of other lifestyle changes and things like that to say oh it's going to take your level from 200 to 500 like i would deem that to be yeah that's legit that's clinically significant but you know the idea that i'm going to start taking a thousand iu or five thousand iu or ten thousand iu please don't take a lot more than that on a daily basis or even up to ten thousand iu a day is generally not a great idea for for a lot of people but um But that alone, absent any other changes, is going to lead to that level of change in real life is very unlikely.

40:16Yeah. All right. Well, let's wrap this case up. I want to pivot to what this means for a person listening to this who's also currently looking at a bottle of vitamin D on their kitchen counter. We've seen the extreme on one side, this young soldier with potential kidney failure and some hypertension. But the subclinical version of this happens more often than people realize. So here are my takeaways from this. One is the testosterone myth, which I think we kind of beat into submission. The engine behind this entire case was the belief that vitamin D is like a pro-hormone for testosterone. As we mentioned, multiple recent meta-analyses have shown that vitamin D supplementation has no significant effect on testosterone levels in men, regardless of their initial testosterone or vitamin D levels.

40:58Whether you're vitamin D deficient or not, taking 10 ,000 IUs a day isn't going to turn you into a pro-bodybuilder. Mostly it's going to turn your blood into calcium soup. The second pearl here is there's some dosing confusion that's happening in the public. One of the most dangerous things to me that's happened in the supplement aisle is the labeling for vitamin D. So in 2020, the FDA began requiring manufacturers to list vitamin D in both micrograms and international units. And so people are often conflating the two. Usually it's like 10, 25, or 50 mic pills is a pretty common dose breakdown.

41:36not too often that I see much higher than that, but if somebody's taking 50 mic pills and then taking enough to get 5 ,000 a day, like that would be, yeah, you get overdosed pretty quick on something like that. Yeah, the math on this is one microgram equals 40 IUs. So if a patient sees a bottle, it says 125 micrograms or whatever, and they think it's a small number, they may not realize that they're actually taking 5 ,000 IUs per serving. So if they double up because they feel tired or they've read something online or a social media influencer says something, suddenly they're taking 10 ,000 IUs a day, which can lead to some toxicity.

42:07Now, Austin, as a physician seeing patients in the hospital, how often are you seeing them when they come in, they're technically overdosing on a medication simply because they either are misunderstanding the directions or they're taking a supplement incorrectly because the label is confusing? Yeah. Unfortunately, it happens super often. I think this is an era of what we'll call polypharmacy. A lot of people are on a lot of medicines. And, you know, statistically, as soon as you're over like three medicines, then your odds of having drug-drug interactions goes way up. And the complexity of dosing ends up getting, you know, to be a bigger problem, especially for people who tend to take more medicines, i.e.

42:46as they get older. So if you have a medicine that, oh, this one's twice a day, this one's three times a day, this one's in the morning before your meals, you know, don't mix these up. And then people start having side effects. And maybe somebody puts them on a medicine to treat that side effect. and then you're even making it more complex and more interactions. This gets messy really fast. And unfortunately, you know, sometimes I'll spend a week working on the wards in the hospital and I'll just take stock of, you know, how many people have I admitted because of a complication of a medicine that they're taking?

43:12And it is, unfortunately, high proportion of the time where people might come in for dizziness or falls or vomiting or kidney issues or, you know, liver issues or something like that related to something that they're taking, which may have been, you know, most of the time is being prescribed, obviously, with good intent, not nefarious intent, but sometimes with insufficient caution or insufficient monitoring or insufficient explanation or instruction or things like that. And so, yeah, to some extent, it's on us, of course. To some extent, it's on the patients, too, in terms of their responsibility to, you know, adhere to these things.

43:45But oftentimes, it comes down to inadequate explanation, education, and, like, shared plan formation of how are we going to go about this. And people can suffer, you know, know, problems as a result. So, um, especially when there are supplements that are not reported or asked about that also get thrown in the mix, then you can augment that risk as well. So it's a, it's a complex world and something that unfortunately I see actually pretty often. Yep. Yep. All right. The next pearl is something we've kind of talked about already, uh, the fat soluble trap. So as Dr. Baraki said, unlike vitamin C or B vitamins, where you essentially just pee out the excess vitamin D is fat soluble.

44:18It stores in your adipose tissue and has a long half-life. Now, our soldier in this case had elevated levels six months after he stopped taking the supplement. So if you overdo it, you can't just detox it out in a weekend. You're stuck with those levels for a pretty long, slow recovery. Now, in a recent review by Bouillon, they kind of explained the molecular why behind this soldier's crisis. So when we talk about vitamin D, we're usually just looking at the total number on the lab report. But this particular review highlighted free vitamin D hypothesis. Most of our vitamin D is carried around by a specific transport protein called vitamin D binding protein.

44:58You can think of this as like a taxi service for the hormone. As long as vitamin D is on the taxi, in the taxi, it's mostly sequestered and safe. Our patient was taking 10 ,000 IUs a day for six months. He essentially saturated every single taxi in the bloodstream. So Austin, you can weigh in on this. We spend so much time talking about the left side of the curve, the deficiency side, but our patient was on the right side, you know, excess. When we look at this from a molecular level, why is it so dangerous to overwhelm these binding proteins and have a bunch of free vitamin D just floating around?

45:32How does this change how we should interpret a standard vitamin D lab test? Yeah, there's a difference not only in this kind of free bound idea, but also like inactive and active forms of the vitamins. So I mentioned, for example, 25-hydroxyvitamin D as a kind of prototypical, quote-unquote, storage form that's not physiologically active. And our body has a lot of complex regulated ways by which it activates vitamin D to 125 or calcitriol. And so there are, in fact, situations in practice where I might put somebody on calcitriol straight up on that active form of vitamin D. And somebody who might listen to this, they might say, oh, why don't I just skip the over-the-counter stuff?

46:11I want to go straight to the active form. I want to get the real deal stuff. And it's like, yeah, that's an even faster route to getting toxic because our body is very good at deciding how much do I need to activate? How much do I need bound, free, et cetera, things like that. The reasons why I might use it is if somebody is physiologically unable to activate their vitamin D, like if they have, you know, a complete kidney failure in their dialysis patients and things like that. And so trying to override these homeostatic mechanisms is often a foolish endeavor. And so you're just going to be in a situation where you're at higher risk of toxicity and unintended side effects if you try to override the system, especially in an unmonitored way.

46:51So that would be among many reasons why. And in this context, especially because of, as you alluded to, how long-acting these things are. Anything that is very, very long-acting, there are even greater concerns about potential toxicity. There are some medicines out there that we use just to deviate a little bit from the vitamin D topic. but medicines that have half-lives of a couple months. And so if somebody develops toxicity, for example, from a drug like amiodarone, like that's an antiarrhythmic drug that's used in cardiovascular medicine. I use it relatively often, but I'm also very, very aware that it's like, if I induce toxicity in this, it is going to take months for this to ends up getting out of this patient system.

47:29There are also, to shout out to one of my favorite podcasts, The Poison Lab in toxicology, there have been toxic exposures and poisonings that have happened with essentially derivatives of like rodent killer type things that are often based in coumarins, so like blood thinning type medicines. And so those are so long acting, lasting for months on end, that people are having to take like massive doses of vitamin K to counteract it because they're at elevated bleeding risk for months on end. And at any given time, if they were unable to keep up with that, that they would essentially bleed out to death.

48:04There have been some outbreaks and poisonings reported. So those are a few examples of how very long-acting things have unique risks that can be exceptionally challenging to manage. I've heard of and seen cases of severe vitamin D toxicity that, as we saw in this case, take months, drugs that I use that take months, and other poisonings that also take months and months and months to fully resolve. Yeah, this paper had mentioned that they hypothesize that when you saturate all of these vitamin D transport proteins, the binding proteins, that you can get some spillover of free vitamin D. And it does tend to be somewhat active.

48:43It's unbound and it can enter these cells like unregulated. So like the taxis aren't dropping off the vitamin D appropriately. It's just kind of going places. And that potentially triggered this patient's case. It is a hypothesis. We don't know that exactly yet, but I found that interesting. To close this out, I think we should look at the updated clinical practice guidelines from the Endocrine Society, which marked a significant change in how many approach vitamin D. For many years, many in the fitness and medical communities have operated under the assumption that we should be testing everyone and aiming for a specific number for vitamin D levels, usually like 30 nanograms per milliliter.

49:23Now, these new guidelines move us away from that treat-to-target model and towards a more nuanced, evidence-based approach. So here's the breakdown of what is now recommended in these clinical practice guidelines. First, for children and adolescents age 1 to 18, they do recommend vitamin D supplementation, primarily to prevent rickets. There's some evidence that also may lower the risk of respiratory tract infections in this population. for pregnant individuals. They also recommend supplementation, potentially lowers the risk of preeclampsia, preterm birth and neonatal mortality. Third, for adults and with high risk like prediabetes or diabetes, the guidelines suggest supplementation in addition to lifestyle modification to reduce the progression of type two diabetes.

50:11And the trials reviewed, the average dose was around 3 ,500 units, international units per day. And then fourth, for adults age 75 and older, they also recommend supplementation of vitamin D just due to the potential mortality benefit identified in a number of meta-analyses. However, for the people that are listening to this podcast, most of them anyway, those between the ages of 19 and 74, they suggest against routine supplementation beyond the current dietary reference intakes, which are about 600 to 800 IUs per day. Perhaps the most significant change, and people may be surprised to know this, they recommend against routine vitamin D testing.

50:52They suggest against screening in the general population, including those with obesity or with various complexions, if they are otherwise healthy and do not have established medical indications like hypocalcemia or malabsorption diseases. Importantly, they no longer endorse a universal target of at least 30 nanograms per milliliter for sufficiency. They've acknowledged that the evidence does not support a single threshold for all people and all conditions. And the costs and risks of widespread testing often outweigh the benefits in this population. So, Austin, the Endocrine Society just flipped the script on this 30 nanogram per milliliter target.

51:31You know, why did the medical community move away from this target? Or are they moving away from this target? Because this is relatively new. I think this paper was published in 2024. 24 and how would you talk to a patient who is worried because their lab result says 28 yeah uh this is a pretty murky area i would say i think that you know there's been a lot of views around how we set diagnostic cutoffs how we set lab cutoffs are we setting something that correlates with overt deficiency versus what's enough for a large enough swath of the population sufficiency there's a spectrum of kind of nutrient status and then there's also the murkiness of like, how much is our blood vitamin D levels actually a marker of nutrient status?

52:11Because we've talked before about how they tend to correlate with general health in a lot of ways. As people get unhealthier in general, they tend to go down. And as health tends to improve, they tend to also improve for varying reasons, not just related to, for example, how much you get in your diet. There's obviously a lot of other factors that can impact vitamin D levels. There's been ideas, for example, that instead of treating to a particular target vitamin D level, that we should maybe treat to the level that leads to the most suppression of parathyroid hormone. That maybe that means that as parathyroid hormone goes up, maybe it's going up because you are relatively vitamin D deficient, leading to not enough calcium in your blood and PTH has to make up the difference.

52:50That's another hypothesis. And it's like, I would want to have some sort of prospective cohort or prospective evidence saying that, oh, if I treat people to maximally suppress their PTH, that some real outcome that a patient might care about is better. Maybe they have some better quality of life or longevity or lower osteoporosis fracture risk, something like that to hang my hat on. Short of that, it's just biochemical evidence that it's like, that could make sense, maybe. And I don't feel super strongly in almost any direction here. Like if somebody wants to do that, okay, I just don't have a strong sense of confidence that they're going to benefit.

53:27But if, again, if it's being monitored, then I don't have a great sense that it's going to be harmed. And so then it comes down to like, what are the costs and who's paying? And if they're like, I want to do this, I'm going to pay money, I'm going to monitor them. Okay. But as far as generating guidelines for public health and saying we need insurers to pay for all of this, and it's like, no, we definitely need stronger evidence to say that this is going to be worth the time and the effort and the expense to do if we're going to have public payers or third-party payers actually addressing this kind of thing.

53:55For somebody who gets their levels checked and it's like, as you said, 28, for example, and they're very concerned, I would elicit those concerns. Tell me what you're most worried about. Also be curious why it was checked in the first place. Was it one of those kind of what we call phishing expeditions of I was just curious, so I got it done to see? Or was there some clear, compelling clinical indication? And then the last part would be, do they have any other medical conditions like the ones where you mentioned where there's actually maybe evidence that they should be? For example, do they have multiple sclerosis?

54:22Yeah, that's a situation where no doubt I would actually have them supplementing because there's actually a little bit better evidence in the context of MS compared with many other conditions. If they said, I'm doing it because I just want to get that extra boost on my testosterone. It's like, well, we got some conversations to have and probably, you know, I bet you'd probably get better results from just like maybe sleeping an extra 30 minutes a night or something like that instead of doing something like this. So really, it's eliciting the person's concern, seeing if there are strong medical reasons to do it.

54:50And then if not, then kind of trying to work through and adjust those expectations as needed. Yep. The last part about the new guidelines is that when supplementation is indicated, the guidelines stronger prefer a daily lower dose administration over the intermittent high dose, like bolus therapy, like those taking 50 ,000 or even 100 ,000 I use once a week or once a month. These high doses may actually increase the risk of complications in certain populations, whereas daily dosing tends to mimic the natural physiology more closely. So as we close this out, the case of the soldier we discussed today is a reminder of why these guidelines matter and why evidence matters.

55:32More isn't necessarily better. Now, for most people listening to this, those under the age of 75 probably don't need vitamin D supplement unless there's a specific reason for you to do so. Chasing a specific lab number does not tend to improve health outcomes just in and of itself. As always, it's nuanced. So if you have a specific medical condition, like inflammatory bowel disease, if you've had your GI tract surgerized, like metabolic bariatric surgery, yeah, these guidelines don't really apply to you. You should follow your doctor's recommendations. But for the average lifter, vitamin D supplementation is probably not going to turn you into an elite-level power lifter or a pro-bodybuilder.

56:14Austin, any final thoughts on the soldier with the leaky skeleton before we close the books on this case? No, that was a super interesting case. And I'm glad that we were able to get to a resolution and find a sufficient explanation for the whole thing. You mentioned that for lifters, the vitamin D is not super likely to be a total game changer for them. A slight interesting correlate to that, I guess, is not in the strength training barbell based population, but rather in the endurance and definitely in the ultra endurance world. those folks are at risk for a variety of reasons of what are called like bone stress injuries and things like that, especially as we've talked about before in the context of inadequate calorie intake and low energy availability, especially when people get very thin.

56:57And that's actually a situation where I have advised some folks to take some vitamin D. There is some evidence that it can lower the risk of bone stress injuries and things like that coming up in that population. I know that that's a tiny sliver, if any, of our regular listening audience, but that's another situation where it would actually be more reasonable to supplement, definitely under monitored situations, like you're getting the levels checked over time because that's a common issue in that population. Yeah. And that's usually for people with a relatively high volume of training, not like three hours a week of conditioning.

57:30That does not count as high volume. Agreed. All right. So that's it for this medical mystery episode of the Barbell Medicine Podcast. If you enjoyed this format, let us know in the comments or on the forum. We've got a lot of new stuff coming your way this year. If you want to support what we do, head to barbellmedicine.com, check out our stuff. Before you go anywhere, please leave us a five-star rating and a review. It really helps drive traffic to our podcast so we can keep bringing you all the latest nuance and health and fitness. For everyone at Barbell Medicine, I'm Dr. Jordan Feigenbaum.

57:57Special shout out to Dr. Austin Baraki for joining us. We'll see you on the next episode.