Do vitamin D supplements work? | Prof. Tim Spector and Dr. Federica Amati

26:53So the idea is that once you've discovered the genes for something, for say vitamin D, and I actually led a study of this about 10 years ago showing that not only was vitamin D genetic, but that you could determine what genes controlled it. So there are about 10 gene variants that we've all got that can make your vitamin D liver higher or lower. This is the thing you were saying before, that actually amongst different people, like my wife and I might be making very different levels of vitamin D, even though we're eating the same food and we're having the same amount of sunlight. Exactly. And it might be perfectly healthy for you to have lower levels than your wife, because your genes have decided that's what they want to do.

27:32We're not sure. We don't know which way around it works. But you would expect that if you've got the genes for low vitamin D, then it doesn't matter what stage you are at life, you're going to have had lower vitamin D levels than your wife. So it's like doing a randomized trial lifelong because you can't change your genes. They can't be influenced by your disease. They can't be influenced by whether you live in Spain or Iceland. It's the same. So this was supposed to show that people with these low vitamin D traits, these low vitamin D genes, should have higher fracture levels. And they've done this in over a million people now.

28:11and there's absolutely no difference. There's no difference whatsoever if your genes are making more vitamin D than someone else. Absolutely none. So if you combine that with the meta-analyses of all these randomized trials, really the evidence that vitamin D supplementation has any role in bone health once you're out of that rare deficiency range, it doesn't exist. And there's some evidence from about three trials where they gave quite high levels of vitamin D that you make it worse. And actually, there was one trial that showed that, actually more than one trial, that showed that if you have the vitamin D plus calcium in some populations, older people can increase risk of cardiovascular disease.

28:57So that's where the vitamin D calcium supplementation issue comes up. And, you know, I'm always quite wary if people are taking large amounts of calcium supplements because, again, the thinking there is that it could help with your bone health. Well, there's even less evidence that calcium supplements work compared to vitamin D, and there's even better evidence that it's really harmful for you. So I don't think anyone listening, unless they've been given specific advice by their doctor, should be taking calcium and supplementation. Because there's quite a lot of evidence, both in animals and in humans, that it can lead to atherosclerosis, a sort of clogging up of the arteries.

29:34because you think about getting calcium naturally from plants or dairy or whatever form it is, you're getting small, tiny amounts all the time regularly, which your body's used to. To take a big one gram tablet of this once a day that your body's got to deal with, we're not meant to do. And it's not surprising that it ends up in the wrong place. You are saying that unless a doctor has specifically prescribed calcium supplementation, And Tim, you think people should not be taking it because you think it's not just that it's neutral, it's positively harmful and can hurt your health. Absolutely. And particularly your heart.

30:13And particularly your heart. Because I think it's rather terrifying, right? Because you can't buy it at the store anywhere. It doesn't have great big labels on it saying warning. Have we known this forever or is this different from what we understood 20 or 30 years ago? We've known it for the last 10 years. but such is the difficulty of changing medical mindsets and the power of the supplement industry that really hasn't still got mainstream and so most family doctors are still prescribing it although many of the specialists now are not. People who suffer with osteoporosis or bone disease sometimes are prescribed both and the randomized controlled trials even in the groups who have a higher chance of problems like osteoporosis the trials clearly show that the vitamin D plus calcium combination is not helpful.

31:02And it's not helpful for the bones and actually could be dangerous for your heart. So it's interesting that it's very clear in the research, but as Tim said, people still take it. And I've seen it as well, where people come to me and they say, this is what I'm taking. I'm like, let's not take the calcium. And what about the vitamin D alone? So I think you're saying very clearly, like if a combination with calcium is like definitely out, is there any downside of taking these vitamin D supplements? Is there any risk? Can I take too much? Absolutely. We didn't think there was, but in the last 10 years, there've been several trials where they've given people larger than 400 units up to 5 ,000 units a day, and many people are self-medicating.

31:43And in these trials, they've shown that the group that were having, say, vitamin D by injections or large amounts by mouth had increased fractures and increased falls. So the researchers in those trials have really changed their minds about it. So you can overdose on these and increasingly in clinics, we're seeing people who are self-medicating from the internet. You can get very high dose tablets from the internet, which seems very strange. And these are very, very dangerous because you do accumulate the vitamin D in your body. It doesn't just get peed out like some other B vitamins. So you will get more and more levels and that can cause real problems, nerve problems, muscle problems.

32:27And because it's called a vitamin, people think it's harmless. It's not just getting passed straight out if I don't need it? Correct. That's right. It does depend on the form you're taking it. But in general, that's correct because it does build up and it is dangerous. So again, it comes back to this idea of taking a supplement in a chemical form is often different to, you know, you can't get too much from sunlight or from food. I think that's really important. So in that sense, it's more like a drug, right? Like I could take paracetamol, that's great, it helps with my headache, but I know that if I have loads of there, you know, it could really hurt me or kill me.

33:02And so you're saying that I should think about vitamin D a bit more like that. Yeah. So when you go and buy Tylenol, you're not allowed to buy, you know, 500 of those tablets, but you can buy unlimited amounts of vitamin D and self-medicate. And I think it's just wrong. And if it was called a steroid, you wouldn't have this. It would be more controlled. And that's why, you know, our body is well set. I can go in the sun as much as I like, and as you may have noticed, I've been in the sun, but my vitamin D isn't going to keep going up. My body knows when I've got enough. We have a system for controlling it when it comes from food or sun, we don't have any system to control it when we're having it as a pharmaceutical.

33:42Everything we've talked about has really been around bone health and the impact on fractures. Is that the whole role of vitamin D? Because I feel like lots of people are taking it because they think it's going to help with their general health. And does that also mean that if I'm not worried about fractures, then I can keep taking lots of it because I don't think that's a very big risk for me? No, there's so much more to the research and there's so much more to how we think vitamin D works. So we spoke at the beginning, Jonathan, about its role in immune system function. And I think that's where research has been more promising for the use of vitamin D, even as supplements.

34:15Because, for example, with groups of patients who have, for example, Crohn's disease, which is an inflammatory disease, we see that those individuals benefit from vitamin D supplementation in randomized controlled trials. They have a reduced risk of hospitalization and of complications. Now, if we think about this as a steroid that helps immune system function, in individuals who have complicated inflammatory diseases, it makes sense that supplementing with vitamin D could help to mitigate some of these problems. Another group that has seen some good outcomes in the VITAL trial is patients who have cancer.

34:51Now, not to prevent cancer, but if you already have cancer, taking vitamin D could actually help to reduce mortality risk. Now, Now, again, this is in a subset of patients, so patients who don't have obesity, whereas patients who do don't seem to benefit. And that probably comes back to how the vitamin D is stored in tissues. So again, try to understand how this works in our bodies is really important. And so where I stand is like there is exciting evidence that this could be helpful in certain groups of people and really make a difference on the outcomes for those people. And so where does this leave the two of you on supplementation?

35:26I'm living in a northerly clime, which is dark all winter. And that is going to be true for, you know, quite a few of our listeners. And I think they're getting this message that you're just not going to get enough from the sunshine during the winter. So you should supplement, that is the outside. Should there be supplementing? And if so, how much? There is reams of evidence that getting outside all year round is helpful for our health for lots of reasons, not just vitamin D. Now, if you get outside all year round, including in the summer months being mindful of your skin tone so some people listening to this like myself and definitely like tim can get outside and not wear a strong sun sunscreen and not get sunburned right other listeners listening know that if they go outside for more than five minutes they will get sunburned sunburn is always a risk factor but if you can go in the sun and enjoy 15 to 20 minutes outside without sunscreen without getting burnt so with no redness, then doing that every day is recommended.

36:25Remembering that we accumulate vitamin D means that if we get enough sunlight exposure in the months when there is sunlight, right, then we'll probably have enough to carry us through the winter months. But if you're somebody who can't get outside, if you're somebody who has perhaps a really sensitive skin tone and finds it difficult to go outside, or if you're somebody who already has compromised health, so maybe you're an older person living in a care home, maybe you have Crohn's disease, or maybe you've just been diagnosed with cancer, then it may be worth speaking to your healthcare professional and getting some vitamin D supplementation because it could be helpful.

37:01But I will really, again, come back to this vitamin D toxicity. I've seen vitamin D toxicity and it's really not fun. There is a lot of influences online that are promoting very high levels of vitamin D. So the takeaway way for me with vitamin D is if you're in one of these groups who could benefit, make sure you're getting the 400 international units in the UK. That's 10 micrograms. In the US, they recommend up to 800 international units, which is 20 micrograms. But really, if you're taking 400 international units a day in one of these groups, you could see a benefit. So I don't completely disagree with Federica, but I don't want to give the impression that everyone living in Northern Europe or parts of Northern America and Canada, you know, should be so dependent on vitamin D.

37:48I think we've evolved for tens of thousands of years to have the right conditions for our body. So we mustn't forget that. And if we have a diverse diet, then, you know, that's also going to help us. There are some conditions that, interestingly, I'm pretty convinced vitamin D can prevent. And one of those is something called multiple sclerosis, which many listeners may know about and my mom actually suffered from. And there's a link between people getting multiple sclerosis who live actually in northern hemisphere and in cold climates, and it gets less as you go towards the equator. And this is one where this Mendinian randomization studies actually showed a difference in the likelihood of getting multiple sclerosis.

38:36So there are some rarer diseases where this can be useful. And I think it makes sense. So if you've got any family history or risk, then making sure your vitamin D level is adequate can be fine. Now, my mother's got it, so I've got a high risk, but I know my vitamin D level is high because I go in the sun, I have a good diet. So I'm not going to take supplements. But someone else might, if they're living in Alaska or living in Scotland, then it'd be quite reasonable in the winter months to take those supplements. But I think we've got to realize that, you know, I would say sunlight and food are a much better option for the vast majority of people.

39:16That's really clear. And we've gone on a little bit, but I do want to make sure I touch a bit these alternate ways of getting vitamin D. And so what are some of the foods that contain vitamin D? Well, most people know that it's contained in dairy products, which a lot of people are already eating. So milk, cheese, cheese, kefirs, yogurts, et cetera. Then it's in oily fish and it's in mushrooms. And they're the key ones. And many people are not incorporating those in their diets. And that's why I think it's been quite interesting, this journey with Zoe and the nutrition program that we're seeing.

39:53We're getting people to eat these kinds of foods, incorporate them more regularly into their diets. And that's just one example of how we can sort of shift people's attitudes foods to foods so that they don't need supplements just by thinking intelligently about what they're eating. If we think about it in proportions, I think up to about 30 % of our requirements can come from the food we eat. It could really make a difference to that absolute minimum level of vitamin D you're getting compared to the sort of people living in these terrible conditions 100 years ago you're talking about. But compared to the sort of numbers that the government is talking about, this now pushes you over to sunlight, is that right?

40:30As the much bigger thing that would drive your vitamin d levels being outside yeah that's interesting because a lot of place countries suffering for the most vitamin d deficiency are places like australia where they're now avoiding the sun and living in air-conditioned you know the inside for six months or more of the year so as we're changing our environment away from nature we are sort of developing some of these new problems it's about how we you know live with our evolution and our nature and everyone has to decide you know what those special examples are that brings up a good point though jonathan as well if you're if you're a person of color and you have darker skin and you live in these like cold climates then you are at higher risk because that sunlight that will actually penetrate your skin and create the vitamin d you won't get that in london right very rare or maybe like a couple of weeks a year.

41:24So to Tim's point, we've evolved to adapt to our environment, but now we're such an international community all over the world. We have to be aware of what we need for ourselves and our backgrounds to make sure we don't lack. But also another important point, we talk about sunlight. I want to be super clear here that sunlight does not, there's no hack for sunlight. So having a sunbed so that you create vitamin D is not the way to do it, right? There's this fine line between getting enough sunlight exposure, but not increasing your risk of cancer, of skin cancer. Well, I was going to say, Federica, so both Tim and I are married to dermatologists.

42:00So I happen to know that Tim created a storm in dermatology circles earlier this year, because the idea of going out in the sun without sort of, you know, factor 50 sunscreen is very controversial because quite reasonably, dermatologists spend a lot of time dealing with people with skin cancer and people who end up dying from skin cancer, right? So they see that. And therefore, there's been these very big campaigns, right, across the States and Europe, Australia, about the extent to which whenever you go outside, you should make sure that you have a really high sunscreen. And I have to say that since I met Justine, I've wear way more sunscreen than I had done before.

42:42And you look so young, Jonathan. Well, thank you. And I am totally convinced that this is great for anti-aging. So I'm sold on that. But I think, Tim, you know, this conversation brings around this question about what the impact might be on vitamin D and health. And I think you had what I thought was a fairly nuanced position, but was interestingly very controversial. So will you tell us how you think about sun exposure and sunscreen, given this conversation of vitamin D? It was triggered both by a research article I read, which was actually on mice, which normally I don't pay much attention to.

43:16But it was showing how vitamin D was really important in helping the immune system deal with cancers. And the other thing was going in the tube and seeing posters by a UK skin charity, but basically sponsored by a sunscreen manufacturer to say that we need sunscreen all year round in order to stay young and beautiful and to protect us from the harmful rays of the sun. And the idea has permeated that we need 365 days of protection with a chemical, a pharmaceutical on our skin has permeated everywhere. So there are some schools in the US and the UK that won't let their children go unless they've got sunscreen every day.

44:03And this is quite ridiculous in northern climes, where you need every little bit of sunshine just to get enough vitamin D. You're not going to get any harmful radiation in that time. It's not going to make a significant difference to your aging. And dermatologists are seeing more and more problems of particularly young girls with major skin problems, because they're applying so much chemicals to their face. And this just seemed to be totally driven by the sunscreen industry, who are going through charities and making it sound like it's all scientific. When I looked into it and when I asked melanoma experts like my wife, there was obviously no evidence.

44:44And after about 2 million people had seen this tweet, and I got lots of nearly death threats for sort of insinuating that sunshine might be good, including from doctors and celebrities and various other people. It turns out the British Dermatological Association came up and said, actually, you know, he's right. There's no rationale for year round use of this. And you need every bit of sunshine you can get in winter. So you're basically suggesting sunscreen in the summer when the sunshine is high and you've got this risk of burning all the rest of it. But actually, you know, if you're not lucky enough to be in Florida in the winter or whatever it is, actually your view is you're better off not having the sunscreen because you're going to increase the vitamin D and that is much better than what you're saying, like not really real risks that they're worrying about to do with skin cancer.

45:33Correct, it's more likely to do harm than good and definitely your skin health will probably be better if you don't have all these layers on every single day of your life. Federica, too radical in your opinion? Well, tell that to women who wear lots of layers, but anyway, I think the main thing there though is we have to be mindful of sunburn again. So I, with children, especially, we know it's, the evidence is really clear. Sunburn in childhood increases your risk of melanoma later in life. And so when it comes to protecting children's skin, or again, if you're somebody who's got extremely fair skin, I think we know that you only need about 10 to 20 minutes of sunlight exposure between 10am and 2pm to produce enough vitamin D.

46:16So you don't necessarily have to have prolonged exposure with no sunscreen. It's just about getting enough in every day. And I do agree with him 100 % though, that we don't need to be wearing SPF 50 throughout the winter months. It does just seem like a complete waste of money and a waste of a layer on our skin. But try buying a foundation cream for women that doesn't have SPF 30 or 50 in it. It's really hard. So women are not given the choice really, actually. That's the other thing that's quite interesting. I'd like to talk about covid actually briefly in the immune system because i think that was a another big area that when i i was talking about vitamin d and preventing covid you might remember that there was a huge thing about taking it and this was absolutely crucial it was like 5 000 international units a day to prevent people were everything sold out as usual in this area in a bid to prevent it and we did our own study with zoe looking at supplements and people what they were taking and interestingly we looked about a million people and saw the severity of covid we saw a slight effect of vitamin d but only in women this was a self-report observational study the fact that it wasn't consistent in men we said it's probably just selection bias and that women were buying it and they believed in it for the family and the men were just you know and therefore it didn't help them so it was a placebo effect but other studies have shown no benefit in COVID for vitamin D.

47:43And there were some big studies about injecting it for people with the disease that didn't show it unless they were very deficient. So people, again, in this sort of really deficient category will benefit from vitamin D. And it's, again, this nuanced argument that it's really hard to convey to the public that if you're severely deficient in vitamin D, giving it can be life-saving it. But if you've already got reasonable levels, having anything extra is really unlikely to help you at all. And I think the same goes, you know, these studies of cancer and all the things related to immune system, autoimmune diseases, et cetera.

48:19So I think that's where we just need to think, are you really deficient or not? And only if you're really deficient should be really worried about this. Otherwise, I think sunshine and a diverse diet is going to be all you really need. And we should be worrying about other things and spending our money on other things. And that's why I think ZOE members who are getting all this education are in a much better position to think about the things that are really important in their health that they can make changes to, rather than just spending huge amounts of money on supplements that are proven not to work.

48:56Do you know someone who worries about their vitamin D levels or maybe worries about their bones? Maybe they're unsure what a healthy vitamin intake really means. Why not share this episode with them right now and empower them to make better decisions based on the latest scientific advice? I'm sure they'll thank you. So it feels like you're basically saying, for most people, they could save all the money they're spending on this vitamin D supplementation and spend it on something else that they're going to eat that is going to have a much bigger impact on their health. Is that? Spending more on real food, getting mushrooms, for example, that have been suntanning, the oily fish occasionally, you know, just a more diverse diet and realizing that, yeah, just putting their arms in the sunshine and walking in the woods and the garden regularly is good for you.

49:46I think moving away from this miracle fix of the vitamin is really important for these other aspects, this more holistic view of life. I mean, and I'm personally about this, about the vitamin D supplementation for the last three years, as Tim knows, but I'm coming away from this podcast pretty clear that as long as I'm able to get some sunshine, it's out the window and I should be thinking about, you know, what am I doing really to feed the good bugs? Good man, you've got it, finally. And I think for those people who have caring responsibilities, maybe you have children, maybe you're helping with an elderly parent, having it in the home and maybe occasionally giving your child some or giving your elderly mother some isn't going to do them harm.

50:25But there's other things that we can do for our health, which are going to have a much bigger impact and actually measurable improvements to our health. So if you've got some in your cupboard, you don't have to throw it in the bin. But definitely don't worry if you skip a few days, unless, as we said, you're in one of these minority groups of people who do have a specific condition that could benefit. Brilliant. Well, look, Federic and Tim, thank you very much. And I think for the listener, I hope that was fun because you can definitely see that there's agreement on what the studies are and what they say that you can have two scientists looking at this and still have some spread of opinion.

51:02And we've had a lot of conversations like this over the last seven years, and I imagine we will have many more. I'm going to try and do a quick summary, if that's all right. So my biggest takeaway from all of this is do not take calcium supplements. Like if I think anyone listening, if there's one thing to take away is don't take calcium supplements unless they've been prescribed. And if you have friends and family who are taking calcium supplements, again, ask them, like, has the doctor actually told you to take this? And if not, you should stop. So I think that's actually probably the most valuable thing I've taken away.

51:30Secondly, vitamin D is not even a vitamin. That does matter a bit because it means that, for example, you really can overdose on vitamin D and end up with something that's toxic because you're saying if it was really a vitamin, you'd just sort of pee it out, but actually it sort of builds up. And so that really should shift the way that I think about it and everyone else would think about it. And then the other bit is there's this huge gap between what the government is saying in terms of saying maybe 30 % or more of the population is deficient in vitamin D. And what you can really tell from people getting rickets or some of these other diseases, which is a tiny, tiny fraction.

52:09And so there is a big debate about really, are so many people deficient or is it actually just a product of the fact that we're all different and our genes are different. And that the evidence on this has really shifted over the last 20 years where previously, you know, Tim was saying he also thought vitamin D was really good and would prescribe it because it was going to reduce fractures. And basically the data, the studies, one after another, have been drip feeding and saying, actually, there is no evidence that if you take this vitamin D, it's going to reduce your risk of fractures, which was the original idea for are taking it and there is real evidence that you can overdose on it.

52:49So if you are taking really high levels of vitamin D, unless your doctor has told you to do it, like stop again. And then I think critically, while there may be some groups, and Federica is pointing out some groups where supplementation could work and interesting, you're tending to talk about groups that might actually be living with some sort of disease. Maybe there's a role for people who are very old and in care homes. I think, Tim, you said that's also possible, but these are relatively small groups, what we should all be doing is rethinking our attitude to the sun, particularly in the winter for people who are living in very northerly or southerly climes, or people who are living in a place where it's hot and they're putting on so much sunscreen like Australia or Florida all year round that they're getting none.

53:36And that actually we need to rethink this balance between, yes, you want to avoid cancer, you don't want to burn, but on the other hand, you do want to get some vitamin D from your skin. And that for a lot of people, that means that you could probably go out in the winter months without having to have sunscreen. And just to wrap up, I would say I have had a personal dispensation from my wife that, you know, in the winter six months, I'm allowed to not wear sunscreen. So, and I think that her view has changed since I've known her. So I think what I see there, I think, Tim, is it's obviously a shift also in medical views from dermatologists and others as this evidence is changing, right?

54:16That the vitamin D is seen as something that matters if you can get it through something like the sun, whereas this supplementation has come under much more question. Yeah. And I think Tim's been saying this for a while, actually. I have to say, Jonathan, he's been very skeptical of vitamin D supplementation for general health and prevention of all disease. And the newer evidence is proving that Tim's approach has been right. And I think quite satisfying for you, I guess, but it's important to always keep an open mind because the status quo on what recommendations are doesn't always hold. I don't want to puff up Tim's head anymore since, you know, we wouldn't want to recommend that.

54:53Could be another study next year that proves me wrong. So, you know. You're open to that. And I'm open to, you know, if there's another way of giving vitamin D that actually works because it's so important in the body. It just so happens that the trials that have all been done so far, apart from, say, multiple sclerosis and a few other rare diseases, have not been effective. But I'm open to supplements working, but let's look at the evidence clearly and come into it with our eyes open and not be driven by the industry into spending all our money on things that are proven not to work. And if I were going to wrap up, I'd just say, I think this reminds me of the conversations we have around food and nutrition all the time, where the latest science is very often completely different from what I was told 30 years ago is the right answer, that it's complex, you have to work it through.

55:46And it's part of the reason we spent so much time trying to figure out how we use the membership in the app to guide people to understand what to change, because this is just vitamin D, right? Like it's just one little part of how you think about improving your health. It is complex. And I think what's interesting is just how many areas scientists are now saying, actually, you know, the view that we had 30 years ago with a lot less data, we've really changed a lot. And that there has been an enormous amount of research that's going on around the world in so many of these areas. I think, you know, Tim is generally saying, well, actually, you know what?

56:19This has really changed, you know, my views and our views about what we should do. But I do think that though the science is complex, I think the advice remains quite simple. and Jonathan, we obviously know this in the app and in the way we speak to our members, but eating a whole food-based diet where you have a lot of plants on your plate and being active throughout the day, preferably outside, is quite simple in terms of the messaging. So I think we mustn't lose sight of the fact that these are all things people can do and it's quite easy to make that change. Obviously, it's easier when you have the help of someone like Zoe to do it.

56:54Yeah, so it's a holistic approach. It's not about one little chemical. It's all about the thousands of chemicals, the whole complexity of our body that we need to embrace. And that's why this whole idea of diversity is absolutely crucial. Brilliant. Thank you both very much. Thank you. Pleasure. I loved having Tim and Federica on the podcast today. I hope you learned something new and enjoyed watching them disagree a little bit. My biggest takeaway is that if possible, we should try to get our vitamin D from natural sources. Now, if you listen to the show regularly, you probably already believe that you could transform your health with food.

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