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Old 02-18-2006, 08:36 PM   #1 (permalink)
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Thumbs up Professor Barbara Gilchrest of Boston University

The Vitamin D Newsletter
February 19, 2005

This is a periodic newsletter from the Vitamin D Council, a non-profit trying to end the epidemic of vitamin D deficiency. If you don't want to get the newsletter, please, please, please, hit reply and let me know.

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I will post this newsletter as a PDF on the website.

Professor Gilchrest

I’m a lot calmer these days. A few years ago, I was angry about the epidemic of vitamin D deficiency and the millions of needless deaths, somehow thinking I had to be more vociferous in getting the word out. Now I just plug along, knowing the truth will prevail, regardless of what I do, knowing we are speaking of decades, not months, for the work ahead. As the poet, Patmore, said:

“For want of me the world’s course will not fail:
When all its work is done, the lie shall rot;
The truth is great, and shall prevail,

When none cares whether it prevail or not.”

I also knew it was only a matter of time before the backlash against vitamin D began. This month, Professor Barbara Gilchrest of Boston University fired the first broadside.

I’m happy to say Professor Gilchrest’s paper didn’t upset me all that much, although, like anything that you don’t agree with, it was difficult to read carefully. Scientists, experts, physicians, and advocates should always read opposing views carefully, less they get drunk on their own whiskey.

Professor Barbara Gilchrest is the same academic who turned me livid eighteen months ago when she fired Professor Michael Holick for writing a book. Holick’s book simply questioned current dermatology dogma that sunlight is evil and she fired him: Boston University’s version of academic freedom.

This time, Dr. Gilchrest teamed up with Dr. Deon Wolpowitz to write a broadside against vitamin D and sunlight. The two authors have something in common: neither had ever published a peer-reviewed paper about vitamin D before (just search PubMed):
J Am Acad Dermatol. 2006 Feb;54(2):301-17. Epub 2006 Jan 4.

Nor did the article get much press. Reuters picked it up, but few other news outlets.
Supplements not sun best for boosting vitamin D

As an aside, Dr. Gilchrest is one of the invited speakers at the upcoming 13th Annual Workshop on Vitamin D in Victoria, British Columbia, from April 8-12, 2006. Professor Tony Norman and Professor Roger Bouillon, both giants in the vitamin D field, organized this meeting. Tickets are going fast. The conference is at the gorgeous Fairmont Empress, a historic hotel one should experience at least once in your life. Be warned, this is a conference for scientists. Most of the presentations are technical, just the sort of work that needs to be done to better understand vitamin D.

However, mixed in with the highly technical papers are some very useful clinical papers. Heike Bischoff-Ferrari, Hector F. Deluca, Edward Giovannucci, Robert Heaney, Bruce Hollis, Jo Ellen Welsh, Susan Whiting, and others usually present their data in ways educated lay people can understand. I was sorry to see that Michael Holick, Cedric Garland, and Reinhold Vieth were not invited to speak – sorry because Holick is the giant of the field, Garland because of his recent incredible paper on vitamin D and cancer, and Vieth because he started the current vitamin D revolution.

At first, I was upset (not livid) to see Dr. Gilchrest invited to speak at a vitamin D conference. However, the more I thought about it, the more I realized this is academic freedom at its best. One of the harshest critics of sun exposure, Dr. Gilchrest, invited to a conference where many of the attendees are staunch advocates of sensible sun exposure. I respect her for coming. I only hope that Professor Norman will invite Professor Michael Holick to debate her. Now that would be a free exchange of ideas!

Getting back to her paper, the most depressing thing about it was the emails from vitamin D experts around the country, bemoaning the fact that it is useless to write a rebuttal to the Journal of the American Academy of Dermatology, useless to try to correct Professor Gilchrest’s mistakes. They have tried in the past - the Journal of the American Academy of Dermatology will not print any view that opposes their dogma that God was confused when she created sunlight. Another blow for free academic discussion of ideas.

After carefully reading Gilchrest’s paper twice, I’m sorry to say the paper contains so many inaccuracies that I can’t list them all. Some of the errors are basic. Professor Gilchrest, cholecalciferol is not previtamin D; it is vitamin D. Professor Gilchrest, vitamin D is not in the “superfamily of steroid hormones that includes vitamin A and thyroid hormone,” its receptor is. Professor Gilchrest, vitamin D is not a steroid hormone; it is a prehormone. Professor Gilchrest, vitamin A is not a steroid hormone; it has a retinol base, not a sterol one. Professor Gilchrest, thyroid hormone is not a steroid hormone; it has a tyrosine base, not a sterol one. When she makes basic mistakes on freshman biochemistry, how can any reader trust her interpretation of scientific studies with immense medical and social consequence?

Her first argument is that sunlight and sunbeds kill many people, mainly due to malignant melanoma. However, she failed to cite the two biggest and best studies! A large, multi-center European study, perhaps the best study ever done on the subject, “found no association between melanoma and risk factors related to UV exposure such as sunbed use, sunbathing, or number of weeks of holidays in sunny areas.” In fact, the authors found sunbed use was associated with a small decreased risk for melanoma! They also found that sun bathing and sunburns were not associated with melanoma. Fair skin and the number of moles were the major risk factor for melanoma, not sunbeds, and sunshine. They even found some evidence of decreasing risk with increasing sunbed use, concluding “The observed decrease in risk (of melanoma) with increasing use (of sunbeds) suggest either a protective effect or could be explained by recall bias with cases under reporting their true exposure.”
Eur J Cancer. 2005 Sep;41(14):2141-9.

Actually, recall bias (errors due to what patients tell researchers they remember), as the authors admit, is likely to skew the results the other way. Patients with melanoma are more likely to report sun exposure or sun bed use in an “effort after meaning.” That is, humans try to find an explanation for their problems and are likely to falsely remember any factor they think might explain their melanoma.

Gilchrest also ignored another recent large European study looking at melanoma and sun/sunbed exposure. The British authors concluded, “This case-control study of melanoma did not find that exposure to natural or artificial radiation was significantly associated with an increased melanoma risk in the population overall.” Although they found ten or more sunburns and exposure to sunbeds for individuals with fair skin yielded significant but small melanoma risks, they found no overall risks. They concluded, “The fact that no dose response was found for hours and years of exposure to sunbeds, even in young subjects, suggests that the use of sunbeds . . . is unlikely to be a major environmental risk factor for melanoma.”
Eur J Cancer. 2004 Feb;40(3):429-35.

After she ignores the two best, biggest, and most recent studies of melanoma and UV light, she goes on argue to sunlight is largely responsible for the 8,000 melanoma deaths per year. In fact, it is more likely that the current epidemic of melanoma, like many other cancers, is partially due to vitamin D deficiency. Vitamin D is such a stellar anti-carcinogen, doing everything an ideal anti-neoplastic drug should do, it is easy to see why dermatologists’ advice to melanoma patients – avoid the sun at all costs – is actually killing patients. A recent large multi-center trial (another one Professor Gilchrest ignored) looked at evidence of ongoing sun-exposure in melanoma patients. It concluded, “Sun exposure is associated with increased survival from melanoma.”
J Natl Cancer Inst. 2005 Feb 2;97(3):195-9

Professor Gilchrest then argues that the health benefits of vitamin D beyond bone disease are unproven. She explains that controlled interventional trials using vitamin D are rare, which is true. However, it is also true that science never proved that low fat diets prevent heart disease or stroke with good controlled interventional trials. The lack of good interventional trials did not prevent modern medicine from advising low fat diets -- uselessly it seems.
JAMA. 2006 Feb 8;295(6):655-66.
New York Times, February 8, 2006: Low-Fat Diet Does Not Cut Health Risks, Study Finds

In implying doctors should not act until scientists conclusively prove a point, Professor Gilchrest misses the point. Sometimes physicians must act before science conclusively proves a point. We cannot wait. Scientists can wait. Physicians are obligated to perform a risk/benefit analysis based on available data and treat their patients accordingly. If a new therapy is highly risky (like a new cancer chemotherapy with numerous side effects), then physicians should only use the drug on patients facing death. If the therapy or advice is clearly safe (drink eight glasses of water a day) and reasonable, it can be widely recommended although I dare the reader to find a single controlled interventional trial showing eight glasses of water a day does much other than increase bottled water sales.

Unlike advising a low fat diet (assuming one also warns against trans-fats and excess omega 6 consumption), advising people to avoid the sun is risky advice. Why is it risky? First, it’s highly unnatural advice to give a species that evolved in the sun. Second, it goes against basic mammalian instincts, as any pet owner will verify. Third, it goes against basic human instincts - the sun draws humans to it - and such instincts evolved for a reason. Finally, it goes against a large body of data that associates both sun exposure and low latitude with reduced incidence of many diseases. Thus, sun avoidance is risky advice and physicians should dispense it only after science has conclusively proven that the benefits of sun-avoidance outweigh the risks.

Consider the advice of the Lancet Editorial Board, commenting on a petition to set aside public land for nude sunbathing! “On first consideration, the idea of a community of people deliberately practicing nudity, especially with public encouragement, strikes the average person as ridiculous. . . But the discovery that the rays of the sun on the skin exert a beneficent effect on health has done something to undermine these prejudices.”
Naked and unashamed [editorial]. Lancet 1932;1:688

Granted, the Lancet proffered this advice in the 30’s, when organized medicine knew the extraordinary health benefits of sun exposure and before the dermatologists scared us out of the sun. Whatever you think of the government sponsoring nudist colonies, you should know that the best physicians in the 20’s and 30’s routinely recommended sun exposure for a breathtakingly wide variety of diseases; many of the same diseases that are now being associated with vitamin D deficiency.
J Am Acad Dermatol. 2003 Jun;48(6):909-18.

Professor Gilchrest goes on to say, “”No trail data support the conclusion that vitamin D supplementation in the absence of concomitant calcium supplementation is effective in preventing falls.” I guess she didn’t have time to read Sato’s recent study that showed a 59% reduction in falls with ergocalciferol supplementation alone.
Cerebrovasc Dis. 2005;20(3):187-92. Epub 2005 Jul 27.

She then cites five “high-quality epidemiological and observational studies,” which “do not support a role for vitamin D in preventing cancers.” The problem is that two of her studies are reviews, both of which call for better studies. Two others found the opposite of what she claimed. For example, the first study she cited concluded, “Calcium supplementation and vitamin D status appear to act largely together, not separately, to reduce risk of colorectal adenoma recurrence.”
J Natl Cancer Inst. 2003 Dec 3;95(23):1765-71.

The other study she cited as showing no effect of vitamin D on colon cancer actually concluded, “This trial cohort provides some evidence that calcium and vitamin D may be inversely associated with adenoma recurrence.”
J Nutr. 2005 Feb;135(2):252-9.

If one wants to review the recent evidence that vitamin D prevents colon cancer, read Professor Giovannucci’s latest paper. He concluded, “Recent studies add more support to a potential role of vitamin D on risk of colorectal cancer, but suggest that intakes higher than customary are required if solar ultraviolet-B exposure is low.”
Curr Opin Gastroenterol. 2006 Jan;22(1):24-9.

Professor Gilchrest also cited a prostate cancer study as negative, which actually showed protective effects for those with mid range vitamin D blood levels, while showing increased risk for those with high and low levels. She failed to point out the author of this study accepted Vieth’s explanation that high levels put one at risk because such patients do not maintain them throughout the year. Vitamin D levels fall precipitously in the autumn and winter. It appears likely that falling vitamin D levels may be as dangerous as low levels.
Int J Cancer. 2004 Jan 1;108(1):104-8.
Int J Cancer. 2004 Sep 1;111(3):468; author reply 469.

Then she makes another mistake, one I cannot blame her for because I have made it myself. She says that we make all the vitamin D we can make in just the first few minutes of sun exposure then we cannot make anymore. Although we make a lot of vitamin D very quickly in the sun, vitamin D production continues to rise with sun exposure - up to about 50,000 units after four minimal erythemal doses (if you stay in the sun four times longer than it takes your skin to begin to turn pink). In 1982, Adams proved that by simply measuring cholecalciferol levels in the winter after steadily increasing UVB exposure into the sunburn range. Increased melanin in the skin (suntan) and other factors will eventually block such robust production.
N Engl J Med. 1982 Mar 25;306(12):722-5.

She also fails to mention the role vitamin D may play in preventing cardiovascular disease (potentially a greater lifesaver than preventing cancer), a topic recently reviewed by Zittermann.
Br J Nutr. 2005 Oct;94(4):483-92.

She goes on to say that if science eventually proves that vitamin D is important, then supplementation, not sunshine, is the answer. That’s risky advice. How does she know all the sun does? She does know that sun exposure increases the risk of non-melanoma skin cancers and ages the skin. She incorrectly thinks sun exposure is the major risk factor for melanoma.

She overlooks the benefit side of the safe sun exposure equation. We know the sun provides vitamin D, which looks as if it may help protect humans from most of the diseases of civilization. What else does the sun do? What does the sun do that we don’t know it does? Before I told someone to avoid the sun, I would wait until science completely understand the relationship between sun and humans. Until then, supplemetation in the colder months and moderate safe sun exposure in the warmer ones, with visits to the dermatologists should you develop signs of skin cancer, is the safest advice.

Remember, non-melanoma skin cancers are mostly a nuisance, unless you ignore them. I have a few frozen every year, thank my dermatologist, and them go out to celebrate, knowing that long ago, science associated non-melanoma skin cancers, a marker for sun exposure, with a reduced risk of dying from internal cancers.
Apperly FL. The relation of solar radiation to cancer mortality in North America. Cancer Res 1941; 1:191-5
The Vitamin D Newsletter, January 18, 2003

She also argues that if you don’t put sunscreen on correctly, and most people don’t, it won’t block vitamin D production in the skin. Thank God! However, she misinterprets Matsuoka’s classic paper which not only showed properly applied sunblock prevents vitamin D production in the skin, but showed casual exposure of the arms and face will only produce minimal amounts of vitamin D. That’s an important point, because some are saying the casual exposure of the arms and face is sufficient. It’s not for many people. Furthermore, does it make sense to expose those parts of your body with the highest cumulative lifetime radiation burden to additional radiation? When I go in the sun, I cover my face and hands but expose as much of the rest of my body as prudence dictates.
J Am Acad Dermatol. 1990 May;22(5 Pt 1):772-5.

Towards the end of the paper, she makes some good points. “Recent reviews have summarized an impressive amount of data showing that hypervitaminosis D from diet (and I infer supplements from her context) is more a theoretic concern than a reality.” Good for her! I guess she read your paper Reinhold? As Reinhold Vieth once said, “Worrying about vitamin D toxicity is like worrying about drowning when you are dying of thirst.” Everyone should read the paper that started the vitamin D revolution. (By the way, Reinhold Vieth’s seminal paper is now free to download thanks to the American Journal of Clinical Nutrition)
Am J Clin Nutr. 1999 May;69(5):842-56.

She also competently discusses that pet peeve of mine. Casual sun exposure won’t work in the winter at many latitudes; it won’t work for African Americans, the aged, and certain cultural groups who veil their skin. Supplementation is critical. Although she sees no reason to strive for natural blood levels (around 50 ng/ml, year around), she does, correctly point out that casual sun exposure will not protect our most vulnerable populations from vitamin D deficiency. Professor Heaney and Professor Hollis have both recently pointed out that many vulnerable patients have to take more than 2,000 units a day, especially in the winter, to prevent deficiency.
J Steroid Biochem Mol Biol. 2005 Oct;97(1-2):13-9.
J Nutr. 2005 Feb;135(2):317-22.

At the end of her paper, a paper filled with inaccuracies, selective references, and apparent ignorance of melanoma literature, she surrenders. She grudgingly admits vitamin D is probably important and the issue needs more attention, even obliquely taking the Food and Nutrition Board to task for not raising guidelines.

However, she doesn’t discuss potential liability for dermatologists – an important omission for her dermatology readers. What will happen to dermatologists who promulgate sunphobia without taking steps to ensure that advice does not induce vitamin D deficiency in their patients? Dermatologists in England have already provided the expert opinion needed in a court of law. After reviewing the role vitamin D plays in cancer prevention, including prevention of malignant melanoma, they concluded: “It would seem mandatory to ensure an adequate vitamin D3 status if sun exposure were seriously curtailed, certainly in relation to carcinoma of breast, prostate and colon and probably also malignant melanoma.”
Br J Dermatol. 2002 Aug;147(2):197-213.

Eighteen months ago, after she fired Professor Michael Holick from her dermatology department, I was livid. I sent Professor Gilchrest a registered letter , threatening to file complaints with the AMA’s Council on Ethical and Judicial Affairs for violating the Principles of Medical Ethics, and with Board of Registration in Medicine of the Commonwealth of Massachusetts for dispensing harmful medical advice. I also threatened to run ads in Boston newspapers to find patients who had developed life-threatening cancers due to her sunphobe advice, patients who could sue her should she not educate herself about vitamin D. After I calmed down, and after Michael Holick calmed me down, I didn’t do any of these things.

Now I’m looking forward to hearing her speak in Victoria at the 13th Annual Workshop on Vitamin D. Even with all the mistakes in her paper, I think Professor Gilchrest has come a long way in the last eighteen months.

Then again, so have I.

John Cannell, MD
The Vitamin D Council
9100 San Gregorio Road
Atascadero, CA 93422

This is a periodic newsletter from the Vitamin D Council, a non-profit trying to end the epidemic of vitamin D deficiency. If you don't want to get the newsletter, please hit reply and let us know.

This newsletter is not copyrighted. Please reproduce it and post it on Internet sites.

Not signed up for the newsletter yet: Vitamin D Newsletter sign-up page

Remember, we are a non-profit and rely on donations to publish our newsletter and maintain our website. Send your tax-deductible contributions to:

The Vitamin D Council
9100 San Gregorio Road
Atascadero, CA 93422
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Old 02-19-2006, 01:34 PM   #2 (permalink)
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Re: Professor Barbara Gilchrest of Boston University

It is my understanding that light skin color is needed in northern climates for the sun's ultra- violet light to penetrate into the body and transform vitamin D into a usable form. She is doing a great disservice to all people who need to absorb sunlight/UV to be healthy. And since the Derms are heavily invested in SPF products, I feel she is actually encouraging any incidences of skin cancer by disallowing a protective tan.
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