The recent Medscape Medical News report of a vitamin D clinical practice guideline released by the Endocrine Society in June triggered an outpouring of objections in the comments section from doctors and other readers.
A society press release listed the key new recommendations on the use of vitamin D supplementation and screening to reduce disease risks in individuals without established indications for such treatment or testing:
- For healthy adults younger than 75, no supplementation at doses above the recommended dietary intakes;
- Populations that may benefit from higher doses include: Children and adolescents 18 and younger to prevent rickets and to reduce risk for respiratory infection; individuals 75 and older to possibly lower mortality risk; "pregnant people" to potentially reduce various risks; people with prediabetes to potentially reduce risk of progression;
- No routine testing for 25-hydroxyvitamin D levels because outcome-specific benefits based on those levels have not been identified (including screening in people with dark complexion or obesity); and
- Based on insufficient evidence, the panel could not determine specific blood-level thresholds for 25-hydroxyvitamin D for adequacy or for target levels for disease prevention.
Medscape Medical News covered the guideline release and simultaneous presentation at the Endocrine Society annual meeting. In response to the coverage, more than 200 doctors and other readers expressed concerns about the guideline, and some said outright that they would not follow it (readers quoted below are identified by the usernames they registered with on the Medscape Medical News website).
One reader who posted as Dr Joseph Destefano went so far as to call the guideline "dangerous" and "almost…evil." Ironically, some readers attacked Medscape Medical News, thinking that the coverage implied an endorsement, rather than a news report.
Ignores Potential Benefits
Although the guideline is said to be for people who are "otherwise healthy" (other than the exceptions noted above), many readers were concerned that the recommendations ignore the potential benefits of supplementation for other health conditions relevant to patients and other populations.
"They address issues dealing only with endocrinology and bone health for the most part," Dr Emilio Gonzalez wrote. "However, vitamin D insufficiency and deficiency are not rare, and they impact the treatment of autoimmune disorders, chronic pain control, immunosuppression, cancer prevention, cardiovascular health, etc. There is plenty of literature in this regard."
"They make these claims as if quality studies contradicting their guidelines have not been out there for years," Dr Brian Batcheldor said. "What about the huge demographic with diseases that impact intestinal absorption, eg, Crohn's and celiac disease, cystic fibrosis, and ulcerative colitis? What about the one in nine that now have autoimmune diseases still awaiting diagnosis? What about night workers or anyone with more restricted access to sun exposure? How about those whose cultural or religious dress code limit skin exposure?"
The latter group was also mentioned in a post from Dr Eve Finkelstein who said, "They don't take into account women who are totally covered for religious reasons. They have no skin other than part of their face exposed. It does not make sense not to supplement them. Ignoring women's health needs seems to be the norm."
"I don't think they considered the oral health effects of vitamin D deficiency," pointed out commenter Corie Lewis. "Excess dental calculus (tartar) from excess calcium/phosphate in saliva significantly increases an individual's periodontal disease risks (gum disease), and low saliva calcium/phosphate increases dental caries (cavities) risks, which generally indicates an imbalance of the oral microbiome. Vitamin D can help create balance and reduce those oral health risks."
Noted Kimberley Morris-Windisch, "Having worked in rheumatology and pain for most of my career, I have seen too many people benefit from correcting deficiency of vitamin D. To ignore this is to miss opportunities to improve patient health." Furthermore, "I find it unlikely that it would only improve mortality after age 75. That makes no sense."
"Also," she added, "what is the number [needed] to harm? In my 25 years, I have seen vitamin D toxicity once and an excessively high level without symptoms one other time."
"WHY? Just WHY?" another lamented Anne Kinchen. "Low levels in pregnant women have long-term effects on the developing fetus — higher and earlier rates of osteopenia in female children, weaker immune systems overall. There are just SO many reasons to test. These guidelines for no testing are absurd!"
No Screening, No Need for Decision-Making?
Several readers questioned the society's rationale for not screening, as expressed by session moderator Clifford J. Rosen, MD, director of Clinical and Translational Research and senior scientist at Maine Medical Center Research Institute, Scarborough, Maine, in a Medscape Medical News report.
"When clinicians measure vitamin D, then they're forced to make a decision what to do about it," Rosen said. "That's where questions about the levels come in. And that's a big problem. So what the panel's saying is, don't screen…This really gets to the heart of the issue, because we have no data that there's anything about screening that allows us to improve quality of life…Screening is probably not worthwhile in any age group."
Among the reader comments in this regard:
"So misguided. Don't look because we don't know what do to with data. That's the message this article exposes. The recommendation is do nothing. But, doing nothing IS an action — not a default." (Lisa Tracy)
"So now, you will not screen for vitamin D because you do not know what to do next? See a naturopathic doctor — we know what to do next!" (Dr Joyce Roberson)
"Gee, how do we treat it…What to do? 🤔 Sounds incompetent at minimum. I suspect it's vital, easy, and inexpensive…so hide it." (Holly Kohley)
"Just because we do not know is not a rationale for not testing. The opposite should be done." (Dr JJ Gold)
Caters to Industry?
Many commentators intimated that pharma and/or insurance company considerations played a role in the recommendations. Their comments included the following:
"I have been under the impression people do routine checkups to verify there are no hidden problems. If only some testing is done, the probability of not finding a problem is huge…Preventive healthcare should be looking for something to prevent instead of waiting until they can cure it. Of course, it might come back to 'follow the money'. It is much more profitable to diagnose and treat than it is to prevent." (Grace Kyser)
"The current irrational 'recommendation' gives insurance companies an excuse to deny ALL tests of vitamin D — even if the proper code is supplied. The result is — people suffer. This recommendation does harm!" (Dr JJ Gold)
"Essentially, they are saying let's not screen 'healthy' individuals and ignore it all together. Better to wait till they're old, pregnant, or already sick and diagnosed with a disease. This is the problem with the healthcare in this country." (Brittney Lesher)
"Until allopathic medicine stops waiting for severe symptoms to develop before even screening for potential health problems, the most expensive healthcare (aka, sick care) system in the world will continue to be content to focus on medical emergencies and ignore prevention…" (Dean Raffelock)
"Don't test? Are you kidding me? Especially when people are supplementing? That is akin to taking a blood pressure medication without measuring blood pressures!…Don't test? Don't supplement?…I have only one explanation for such nonsense: Pharma lives off sick people, not healthy ones." (Georg Schlomka)
On a somewhat conciliatory and pointed note, Dr Francesca Luna-Rudin commented, "I would like to remind all of my fellow physicians that recommendations should be regarded as just that, a 'recommendation'. As doctors, we can use guidelines and recommendations in our practice, but if a new one is presented that does not make sense or would lead to harm based on our education and training, then we are not bound to follow it!"
Marilynn Larkin, MA, is an award-winning medical writer and editor whose work has appeared in numerous publications, including Medscape Medical News and its sister publication MDedge, The Lancet (where she was a contributing editor), and Reuters Health.