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  • 1. Sleep, Vitamins and Family Practice Dr. Stasha Gominak ETMC Neurologic Institute, 700 Olympic Plaza, 912 Tyler, TX (903) 596-3808 www.drgominak.com 2/19/2011
  • 2. Why don’t we doctors know much about Sleep?
    • We all do it. We spend 1/3 of each 24 hours doing it, why ?
    • We all know we feel terrible the next day when we don’t sleep well. What if we felt that way every day?
    • How important is it to our patients?
    • Why don’t we learn about it in residency?
  • 3. Sleep and Headache
    • I became interested in sleep when one of my daily headache patients had sleep apnea.
    • She did not have significant drops in oxygen. She was not fat but she did have obstructive sleep apnea.
    • Two years of trying medications had failed, 3 weeks of wearing a CPAP mask cured her headaches.
    • Why would that be? Could other daily headache sufferers also have sleep disorders?
    • Is something happening in the brain during sleep to make chemicals that are like the daily headache preventative medicines we use; Ca++ channel blockers or Na+ channel blockers?
  • 4. 6 years of sleep studies: 9/10 daily headache sufferers have abnormal sleep
    • Obstructive sleep apnea is just one of the sleep disorders seen in my young, healthy patients with daily headache.
    • Others have multiple unexplained awakenings, no REM sleep, no slow wave sleep, or REM related apnea. They do not have large oxygen drops.
    • Some also kick their legs in sleep; Periodic Limb Movements of Sleep (PLMS). Why?
    • Are these many different disorders or are they several ways of manifesting a malfunction of a certain area?
  • 5. Normal Sleep is a highly organized process
    • what follows are my ideas of what we are doing in sleep and why
  • 6. What is Light Sleep?
    • Light Sleep: We begin Stage I move to Stage II. We are asleep but are easily awakened.
    • I think we are waiting to be sure we’re in a safe place to get paralyzed .
    • I believe that in light sleep we are asleep but not doing the work of sleep.
  • 7. Deep Sleep: Slow Wave Sleep
    • As soon as our brain is sure that we’re in a safe place to get paralyzed (lying down) we enter Stage III sleep. ( Stage III and what was Stage IV are now grouped together as just Stage III )
    • Stage III is called “Slow Wave Sleep” (SWS) because the brain wave pattern becomes slow and synchronized.
    • During Stage III sleep our body becomes paralyzed.
    • Growth hormone (GH) is released from the brain in a pulsatile fashion in SWS , if you don’t get and stay in SWS you don’t get this GH.
  • 8. Growth Hormone in Slow Wave Sleep may help us heal
    • Growth Hormone (GH) is the same hormone that makes kids grow during sleep. In children it is a sustained release during SWS, they grow while paralyzed .
    • I believe that nightly GH in adults may act analogously, as a repair hormone; the “boss hormone” that calls out all of the individual muscle, bone, tendon, artery, nerve, repair factors. In adults paralysis for repair.
    • People with PLMS often wake in the morning with leg or back pain.
    • This may suggest that if your SWS is frequently interrupted or shortened by apnea or PLMS, your repair phase doesn’t happen normally and you may wake up with pain in the morning.
  • 9. Deep Sleep: REM Sleep
    • After SWS we enter REM (Rapid Eye Movement) sleep.
    • In REM sleep we’re the most paralyzed of all (so we don’t act out our dreams) . So milder sleep apnea may present as just “REM related apnea”.
    • Most of my daily headache sufferers have REM related apnea . They also have mood and memory problems, and REM is also where we do memory and mood.
  • 10. 9/10 daily headache sufferers in my practice have abnormal sleep
    • CPAP is great! When it works miraculous things do happen. BP better, headaches gone, tremor gone, diabetes gone.
    • But what should I do to treat the others?
      • Multiple awakenings to light sleep.
      • No REM sleep, no SW sleep.
      • REM related apnea.
      • Periodic Limb Movements of Sleep (PLMS).
    • Why aren’t there any medicines that give back normal sleep?
    • Are these many different disorders or are they several ways of manifesting a malfunction of a certain area? Where does this happen? Why does it happen?
    • If we could fix this we could dump the CPAP device!!!!
    • Because I’m thinking about headache all the time I’m focused on the posterior brainstem. Why is that area important?
  • 11. The Migraine “Brainstem Generator” is in the same area of the brainstem where we do timing and paralysis of sleep
  • 12. Posterior brainstem Periaquiductal Gray plays a large role in sleep and sleep paralysis
    • There are pacemakers in the periaquiductal grey that switch sleep on and off. They are the brain clock.
    • The paralysis switch is here also.
    • They are heavily intertwined so we only get paralyzed while we are deeply asleep.
    • We must all get paralyzed in deep sleep to complete the work of sleep
  • 13. Features of my patients’ sleep disorders: (They don’t have fat necks!)
    • Young, healthy headache sufferers.
    • Some of them get too paralyzed ; apnea results. Some are not paralyzed enough ; their legs or arms or jaw moves.
    • Usually both features are present to some degree.
    • Do they have two separate sleep disorders?
    • Why would young, healthy people have not one, but two sleep disorders? Could it be one problem producing both features ?
    • How could we model a paralysis switch that when it malfunctions causes both findings?
  • 14. The Wobbly Paralysis Switch
    • The bulbar muscles have to be perfectly paralyzed: Can’t swallow you’ll drown, too paralyzed, airway collapses, not paralyzed enough, talk or chew.
    • What if we model the brainstem paralysis switch as more of a speedometer needle, cruise control, perfectly paralyzed?
    • This paralysis switch is run by dopaminergic pacemaker cells in the posterior brainstem.
    • I think these patients have a wobbly paralysis switch going from “too paralyzed” causing apnea, to “not paralyzed enough” causing leg kicks, talking, chewing.
    • Not Paralyzed Enough
    Too Paralyzed Not Paralyzed Enough
  • 15. Simplifying abnormal sleep studies : 2 common features:
    • We could view all of the abnormal sleep studies as having one or both of : problems with the timing of sleep , (falling into appropriate stages)– or--the paralysis of sleep.
    • Both of these features are controlled by the posterior brainstem nuclei and are heavily intertwined.
    • All of the sleep disorders can be viewed as different facets of these two “switches” not operating correctly.
  • 16. If headache improves how about other pain?
    • Some of the daily headache sufferers said their back pain got better on CPAP.
    • So I started sending many of my chronic pain patients for sleep studies.
    • Then the patients who had back pain and abnormal sleep studies got better on CPAP. Why?
    • Why does every one of my patients seem to have an abnormal sleep study?
  • 17. Why does everyone and his brother seem to have Sleep Apnea? Did we make it up? Has it always been there or is it new? What’s causing it? Why is it more in “developed countries”?
  • 18. All over the world 9/10 sleep studies are abnormal. With sleep apnea comes:
    • High blood pressure
    • Heart attack, heart arrhythmia (atrial fibrillation)
    • Diabetes
    • Stroke
    • Obesity
    • Daytime sleepiness
    • Memory problems
    • Depression
    • Daily headache
    • Unexplained body pain (“Fibromyalgia”)
    • Fatigue
  • 19. I thought Sleep Apnea only happened to fat people
  • 20. Does obesity cause sleep apnea or does sleep apnea cause obesity?
  • 21. Obesity and Sleep Apnea
    • In patients with sleep apnea orexin (hypocreatin) ghrelin and leptin levels are deranged causing increased appetite and increase in fat deposition per calorie consumed.
    • Obesity comes with the Sleep Apnea and not the reverse.
    • Losing weight is not the whole story of making Sleep Apnea go away.
    • Lap band or gastric bypass may help temporarily but it does not fix the original cause of sleep apnea. They may snore less but still not have restorative sleep.
  • 22. Why is the CPAP experience important?
    • I spent the last 5 years trying to help patients “tolerate” their CPAP mask.
    • It is very hard to do, therefore has very little placebo effect in my opinion and it’s not a drug.
    • Despite being hard to do, miraculous things do happen when it’s successful:
    • Pain goes away, blood pressure goes down, diabetes gets better, headaches better, mood better, tremor, walking disorders, and seizures get better.
    • But in many patients, over years, we have to increase the CPAP pressure. Whatever is causing this is still getting worse in the background.
    • It’s not the oxygen! It’s the sleep fragmentation.
  • 23. What’s happening here that’s goofing up my patients’ sleep? Periaquiductal gray
  • 24. Why don’t we fix the sleep instead of blowing air up the nose?
    • In July 2009 one of my 18 y/o patients with daily headache and a sleep study showing 35 unexplained awakenings/hour turned out to have B12 deficiency.
    • Adding back a vitamin to fix the sleep?
    • The brain still remembers what to do, but it is lacking an essential element that it needs?
    • The next month one of my patients mentioned her doctor gave her vitamin D and it made her pain better.
    • All of a sudden everyone in my practice gets a B12 and a D level drawn. They all have abnormal sleep studies.
  • 25. Vitamins and Sleep
    • From 8/09 to 12/09 I measured B12 and Vitamin D levels on every single patient who had a bad sleep study.
    • A few of the sickest ones, with the worst sleep, had B12 deficiency but every single D was low. (<30 ng/ml)
    • In December 2009 two of my headache patients, who had been wearing CPAP without improvement, came back and said “after three weeks that vitamin D made my sleep better and my headaches went away.”
    • What?
  • 26. Vitamin D and Sleep
    • What is vitamin D and what could it have to do with sleep?
    • I thought D was all about bones and calcium.
    • Are there vitamin D receptors in the brain? Why would there be vitamin D receptors in the brain?
    • It turns out that there are vitamin D receptors in the brain and they’re concentrated in that posterior brainstem stripe I’ve been looking at for the last 6 years.
  • 27. Vitamin D receptors concentrate in 3 brain areas; periaquiductal grey, lateral ventricles and pituitary/hypothalamus
  • 28. What is Vitamin D anyway?
    • IT’S NOT A VITAMIN!!! It never was a vitamin.
    • It’s a HORMONE that we make, like thyroid, cortisol, estrogen, testosterone.
    • We make it on our skin from cholesterol .
    • UVB light hits the skin and changes 7 dehydrocholesterol to D hormone; cholecalciferol.
    • Every animal on the planet; hamsters, birds, reptiles, fish and insects make this chemical, on their skin, from UVB light.
    • This implies that it is very, very old.
    • Probably the dinosaurs made Hormone D. If it’s found in fish it’s there from way before we all crawled out of the water.
    • What’s it for?
    • Would it have anything to do with sleep?
  • 29. In the 1970’s- 80’s Dr. Walter Stumpf “explained” what D hormone does
  • 30. Dr. Walter Stumpf and D hormone
    • Stumpf WE, Sar M, Reid FA, Tanaka Y, DeLuca HF. Target cells for 1,25-dihydroxyvitamin D3 in intestinal tract, stomach, kidney, skin, pituitary, and parathyroid . Science. 1979 Dec 7;206(4423):1188-90.
    • Stumpf, WE and O'Brien, LP. 1,25 (OH)2 Vitamin D3 sites of action in the brain: an autoradiographic study . Histochem.87:393-406, 1987.
    • Stumpf, WE, Clark, SA, O'Brien, LP and Reid, FA. 1,25 (OH)2 vitamin D3 sites of action in spinal cord and sensory ganglion . Anat. Embriol. 177:307-310, 1988.
    • Stumpf WE, Denny ME . Vitamin D ( soltriol ), light, and reproduction. Am J Obstet Gynecol. 1989 Nov;161(5):1375-84.
    • Stumpf WE, Privette TH. Light, vitamin D and psychiatry. Role of 1,25 dihydroxyvitamin D3 (soltriol) in etiology and therapy of seasonal affective disorder and other mental processes. Psychopharmacology (Berl). 1989;97(3):285-94
    • Bidmon HJ, Gutkowska J, Murakami R, Stumpf WE. Vitamin D receptors in heart: effects on atrial natriuretic factor . Experientia. 1991 Sep 15;47(9):958-62.
    • (This is a small sample of many, many articles.)
  • 31. Why would we have a hormone made by UVB that bosses the pituitary and hypothalamus?
    • UVB is the only wavelength present in summer not in winter.
    • D hormone adjusts metabolism to the two, very different, states of weather and food availability.
    • In the summer we eat lots of perishable food, plow the soil, gather food, build things, sleep little.
    • In the winter there is no food .
    • We hibernate, we sleep more, channel more of the calories we eat into fat.
    • Any animal that can eat very little and still put on a little fat in the winter has a survival advantage.
  • 32. Where are the D Receptors? (Where they are may suggest what they do.)
    • GI tract:
    • Teeth, salivary glands, tongue, esophageal sphincter,
    • Stomach cells that make acid
    • Liver cells that make bile
    • Pancreatic islet cells that make insulin
  • 33. Summer: High D message (70-80)
    • Eat 10,000 calories per day, digest it all easily.
    • Put all of those calories into building the body.
    • Sleep fewer hours ( deep, paralyzed, work sleep done in 6-8 hours).
    • There are D receptors in ovaries, fallopian tubes, testes;
    • The estrogen and testosterone follow the D. September is harvest time, the D is at its highest, it’s time to mate and make a baby.
    • Make a baby in Sept. it’s born in June, baby’s in the sun to make D hormone on his skin.
    • Thyroid follows the D also. All cellular energy increases.
  • 34. Winter: Lower D message (50-60)
    • Because there is only UVB in the summer, after September we start to depend on our D hormone stores.
    • Sleep longer, paralyzed phases much less consolidated.
    • Eat less, but put half of everything we eat into fat. Remember those hormones that make you hungry and tell your body to store more fat? (Orexin, ghrelin, leptin.)
    • Very low D may lead to very goofed up sleep. Could this be the cause of sleep apnea?
  • 35. D Hormone and Sleep
    • This implies there may be a natural reason and cure for the recent epidemic of obstructive sleep apnea
    • There is no proof of this yet, it is only my hypothesis, but the timing and the populations affected make it very likely.
    • Early 1980’s: Begin the epidemics of OSA, fibromyalgia, chronic fatigue and pain specialists.
    • Late 70’s early 80’s; sunscreen, air conditioning, television, and computers.
    • Sleep apnea and associated disorders are epidemic in “developed” countries.
    • Once the electricity arrives so does the air conditioning. Humans aren’t stupid, now when it’s hot we go inside or buy an air conditioned tractor.
  • 36. D Hormone not Vitamin D
    • The sleep connection is the only new observation, everything else was described 30 years ago but you didn’t learn about it in medical school. Why is that ?
    • When the word “vitamin” was applied to this chemical it became overlooked by Medicine and has not been taught to those of us who should be conveying this to our patients.
    • Over the last 30 years all of the basic science observations to support Dr. Stumpf’s theories have been published. Why don’t we know about these articles?
    • They’re in the Nutrition Journals, the European Endocrine Journals, and just the last 5 years, our medical journals.
  • 37. Epidemiologically related to D deficiency- (same list as sleep apnea)
    • High blood pressure
    • High cholesterol
    • Heart attack, atherosclerosis
    • Heart arrhythmia ( Atrial fibrillation)
    • Stroke
    • Obesity
    • Memory problems
    • Depression
    • Daily headache
    • Unexplained body pain (“Fibromyalgia”)
  • 38. Disorders of GI tract epidemiologically related to D deficiency
    • Gastric reflux
    • B 12 deficiency is usually a secondary deficiency caused by D deficiency. (Not enough stomach acid, can’t break the B12 off the meat. Iron deficiency the same.)
    • Poor stomach motility
    • Gallstones, (D and cholesterol are liquid component of bile)
    • Diabetes (islet cells have D receptors)
    • Decreased “good” colonic bacteria with bloating etc.
    • Constipation
    • Esophageal cancer
    • Colon cancer
  • 39. Cholesterol and D Hormone
    • If we make vitamin D on our skin from cholesterol does that mean that everyone in my practice with high cholesterol has a low D?
    • There is conflicting literature concerning this.
    • Are there really two ways to treat this high cholesterol?
    • Give the natural D hormone that’s lacking or give a statin?
    7 dehydrocholesterol Pre vitamin D
  • 40. Cholesterol and D Hormone
    • When the statin lowers the cholesterol does that mean that 7 dehydrocholesterol, the raw material that makes vitamin D, is lower on the skin too? If so does that imply that I won’t be able to make vitamin D now when I go out in the sun?
    • There is conflicting literature on this as well.
    • Might this also mean that my sun exposed areas are now exposed without the protective effects of vitamin D producing more wrinkling, color changes, and bruising?
    • We have the enzyme that makes active D 1,25 OH on our skin, it keeps the skin cells in line, keeps them from turning cancerous or reproducing inappropriately. Keeps the fibroblasts healthy repairing our skin.
  • 41. Vitamin D inflammatory connection
    • There are D receptors all over the WBC’s.
    • Low D appears to increase proinflamatory actions, leading to joint inflammation that in combination with lack of repair in sleep leads to
      • Knee replacement
      • Hip arthritis, replacement
      • Rotator cuff surgeries
      • ? Vascular damage leading to aneurysms and atherosclerosis
    • D is needed not only for bone health but also for fibroblast, skin and blood vessel health .
    • All blood cells have vitamin D receptors, even platelets and red cells.
    • Probably the time that we do most of the maintenance using this hormone is during sleep , so the effect of it’s absence is doubled or tripled by the disrupted sleep.
  • 42. Autoimmune Diseases Epidemiologically linked to D deficiency
    • Rheumatoid arthritis
    • Lupus
    • Ulcerative Colitis
    • Psoriasis
    • Celiac Disease
    • Asthma
    • Allergies
    • Multiple Sclerosis
    • ?Inflammatory aspects of cardiovascular disease
  • 43. Why did they call it a vitamin if it’s not one? Why the “D2” and “D3” numbers ?
    • The original rickets model was established by narrowing down a rat’s diet until their bones got osteoporotic.
    • Oops, rats are nocturnal animals, they don’t go out in the sun. In order to become nocturnal they had to evolve a D receptor that could use the D found in food.
    • The first chemicals found that corrected the rat’s bone disorder were from fungus on grain, named vitamin D1 and D2 . They were, in fact, in the food.
    • Unfortunately what we make on our skin is D3, a different chemical. That chemical may have different effects at different D receptor subtypes within the body.
  • 44. D2 is NOT the same as D3
    • Every non nocturnal animal on this planet including man makes and uses D3, and it’s not in the food anywhere .
    • It is not a vitamin.
    • D2 may have variable effects in different species and different individuals. In my patients it seems to worsen the sleep. It may act as a partial agonist at some sites, partial antagonist at others.
  • 45. What does this D have to do with my patients? Where’s the evidenced based medicine?
  • 46. Vitamin D and Cardiovascular Dz
    • 25 hydroxyvitamin D, IGF-1 and metabolic syndrome at 45 years of age: a cross sectional study in the 1958 British Birth Cohort. Diabetes 2008 Feb 57(2) 298-305. Serum 25 (OH) D is inversely associated with metabolic syndrome. Metabolic syndrome prevalence is lowest when both 25(OH) D and IGF-1 are high.
    • 25 Hydroxyvitamin D deficiency is independently associated with cardiovascular disease in the Third National Health and Nutrition Examination Survey. Atherosclerosis . 2009 205 (1) 255-260. Strong independent relationship of 25 (OH) deficiency with prevalence CVD in a large sample.
    • Vitamin D, race and cardiovascular mortality: findings from a national US sample. Ann Fam Med 2010 Jan-Feb 8(1) 11-18. Black white differences in 25(OH) D levels may contribute to excess cardiovascular mortality in blacks.
  • 47. Vitamin D and Cardiovascular Dz
    • Adiposity, cardiometabolic risk, and vitamin D status: the Framingham Heart Study. Diabetes . 2010 Jan 59 (1) 242-248 . Vitamin D status is strongly associated with variation in subcutaneous and especially visceral adiposity.
    • Vitamin D status and Cardiometabolic Risk Factors in the United State Adolescent Population. Pediatrics 2009 Aug 3. Low serum vitamin D in US adolescents is strongly associated with hypertension, hyperglycemia and metabolic syndrome independent of adiposity.
    • Vitamin D in relation to metabolic risk factors, insulin sensitivity and adiponectin in a young Middle-Eastern population . Eur J Endocrinol 2009 160(6) 965-71. In non obese young subjects we observe new relationships between 25 (OH) D and several metabolic risk factors and adiponectin.
  • 48. Vitamin D and Cardiovascular Dz
    • Association of leptin, 25 hydroxyvitamin D and parthyroid hormone in women. Nutr Cancer 2009 61(2) 225-31. Leptin was highly correlated with the BMI/25 OH Vit D ratio consistent with a model in which BMI and 25 (OH) Vit D are the primary determinants of circulating leptin and PTH levels.
    • Effect of vitamin D deficiency and replacement on endothelial function in asymptomatic subjects. J Clin Endo Metab 2009 Oct 94(10) 4023-30. 25 (OH) D deficiency is associated with endothelial dysfunction and increased lipid peroxidation. Hypoviaminosis D associated endothelial dysfunction may predisopose to higher rates of cardiovascular disease.
  • 49. Vitamin D and Atrial Naturetic Factor
    • Vitamin D receptors in heart: Effects on atrial naturetic factor. Experimentia 1991 47 958-962. In rats vitamin D receptors concentrated in the right atrium, colocalizing with atrial naturetic peptide. Changes in ANF tissue and blood levels under dietary deficiency and treatment with 1,25 D3 suggest direct genomic action of vitamin D on myoendocrine cells of the atrium for the regulation of ANF manufacture and secretion.
  • 50. Epidemiology is fine. What about treatment trials?
    • OK so they’re seen together. Lets see the vitamin D cure the disease.
    • VITAMIN: What’s the right dose?
    • HORMONE: What’s the right level?
    • What’s the dose to get to the right level? This is the hard part.
    • Why is the sleep observation so pivotal?
  • 51. Restorative sleep is the cure for cardiovascular disease
    • We know that correcting the sleep has profound effects on disease.
    • The cure is the sleep, not the D . CPAP is one way, D perhaps another.
    • If it’s a deficiency state why not try treat that first?
    • The curative effect is not D, it’s a perfect D level .
    • Too high D makes the sleep disorder return .
    • 60-80 ng/ml appears to be the range for no pills, no pain normal, restorative sleep.
    • Normal sleep, night after night, is what cures the body.
    • D Lower than 50 appears to bring on the sleep disorder.
  • 52. How to replace the D to fix the sleep and why all the controversy about dosing?
    • From 8/2010 - 12/2010 I had given FDA recommended 1000 IU of vitamin D3 . (Contrary to popular rumor I am not really a vitamin nut.)
    • The two guys wearing the CPAP were the only ones who got better probably because their D levels were higher, in the 40’s, before supplementing and CPAP definitely helps.
    • In January 2010, after learning about D, I came back expecting all my headache patients to be cured, but none were better, they still couldn’t sleep and had a headache every day. So I checked their levels again.
    • On 1000 IU/day their D levels were all 10 points lower . They were 28 in August, 18 in January. So 1000 IU per day is just fine if you start with a level of 80 in August, but it won’t get you normal sleep in the winter if you’re starting below 30.
  • 53. What is the right level ?
    • By February I was giving 2,000 IU/day. “Call me back about your sleep.”
    • And what is a “normal D”? (30-100) If all of my patients with a level of 28 have lousy sleep and a headache, is 30-35 really “normal”?
    • www.vitamindcouncil.org believes the level should be 80 ng/ml in September and no lower than 50 at the end of winter and it takes 10,000 IU/day to STAY THE SAME.
    • What is the right level to achieve normal sleep?
  • 54. What’s the right dose?
    • We make 20,000 IU on our skin in 1-6 hours in the sun, middle of the summer, middle of the day based on skin color.
    • If we’re not out there every day in summer 1,000 IU/day is probably not going to replace this.
    • It is not 10,000 IU to “stay the same” both in winter and summer because we make sun D in summer.
    • What’s the level of a thriving human on no pills with normal sleep and no pain?
    • Probably 60-80 ng/ml
  • 55. The right dose is different for each person. But the right level is the same for all humans (just like thyroid or estrogen)
    • The right dose is the dose that allows you and your patients to sleep normally and wake up rested without a sleeping pill or a pain pill or a reflux pill, etc.
    • The one time dose to replete D stores is much higher than what is being tried in most clinical trials. And is not the same concept as a daily maintenance dose in a patient who’s level is now 60-80.
    • Also for normal sleep, dosing once a week, or a month, does not appear to be the same as daily dosing .
    • The proper treatment trials aren’t out yet because it’s not clear to many of the researchers that this is a hormone, it’s not the dose it’s the level. They’re treating heart disease with 400 IU/day.
    • And they don’t know that it’s the sleep that cures the disease , whether that’s stroke, heart attack or metabolic syndrome.
  • 56. Vitamin D Toxicity and why the FDA’s not crazy
    • All of the “toxicity” refers to hyper calcemia but most of my patients had “toxicity” symptoms way before the calcium went up.
    • In most patients the symptoms of fatigue, pain and poor sleep start to return above a level of 90-95. The abnormal movements in sleep come back leading to pain on awakening again.
    • The sleep disorder comes back with a too high D just like too low D .
    • As with every hormone: go too high things go wrong, go too low things go wrong.
  • 57. Why the FDA’s not crazy
    • This is a hormone with a narrow band of normal. The level changes in each person from month to month and year to year based on sun exposure and skin type.
    • How could the FDA possibly recommend a single dose for all Americans living from Florida to Alaska with very divergent skin colors and lifestyles without screwing everyone up?
    • They wisely chose to recommend a tiny, tiny dose, i.e., not enough to screw anyone up.
    • This chemical should never be supplemented by the government, it’s as odd as putting testosterone or estrogen in the milk.
    • It should never have been over the counter so that we’re not sure how much is in the non regulated pills we’re taking.
  • 58. The FDA recommended dose has absolutely nothing to do with the blood level that should be achieved in a clinical trial to produce normal sleep and cure disease. It also has nothing to do with the dose you want for your sleep to be normal so you don’t have to take those pills.
  • 59. My Observations on Particular Patient Groups
  • 60. Hypertension
    • The sleep study experts have already documented that every American with hypertension needs a sleep study. Why don’t we do it? Because we don’t want them to have to use that stupid CPAP device, and they all have sleep disorders they just don’t all have severe sleep apnea.
    • Hypertension = sleep disorder. Just measure the D get it up to 60 and watch the hypertension resolve.
    • This is especially true in your patients with “hard to control” hypertension. If they sleep well one night the BP’s too low the next day, sleep badly and it’s too high despite the 4 medications
    • Your African American and Mexican American patients have the lowest D levels you will see. They are made for high sun environments and may need 8 hours of sun a day to make 20K D.
  • 61. My Observations on Particular Patient Groups
    • Gallbladder disease; gallstones and dysmotility always has D deficiency in the background. After D is made it goes to the liver. Cholesterol and D make up the liquid part of bile, bile acids the solid. No D bile acids come out of solution.
    • The entire GI tract nervous system, motility of the esophagus, stomach, gall bladder and upper and lower GI tract are linked to D
    • If gallbladder surgery is anticipated try to get the D level up for a month or so before surgery to prevent post surgical complications: DVT, infection, poor healing. Maybe their GB disease will resolve. Short course 10,000 IU/day.
    • All of your patients with atrial fibrillation have low D in the background. Remember the level moves monthly so do your patients’ levels in March-May and you’ll find out just how terrible they really are every spring. Remember it’s the non restorative sleep that causes the heart disease.
    • Most of the patients with heart failure have vitamin D deficiency, especially those with right heart failure and leg swelling.
  • 62. Bone Health
    • Osteoporosis is a vitamin D deficiency disorder . Why are we giving Fosamax, Evista, Boniva etc etc when vitamin D is cheap. It’s free.
    • Get the D level to 60 and take away the expensive, unnecessary osteoporosis medicine and STOP the extra Calcium. When the D gets normal you do not need extra calcium.
    • All of your patients with hyperparathyroidism have this because their D’s are so low that their parathyroid has to work overtime to keep the Ca++ level normal.
    • Your patients with kidney stones usually have low D’s. Normal vitamin D levels keep the Calcium from spilling into the urine.
  • 63. Arthritis
    • “ Arthritis” is the name we have applied to “My__________ hurts when I wake up in the morning, I take a shower and limber up and it goes away”.
    • Each one of these people have low D and a sleep disorder. The parts that are moving or tensing in sleep don’t get repaired properly and hurt in the morning.
    • We make D less efficiently as we get into our 70-80’s so normal aging is made up of: “rheumatism”, don’t sleep as well, bowel’s don’t work and a runny nose. It’s true that older people have “arthritis” but now so do younger people. All from low D.
    • In young people we call this “allergies” “irritable bowel” “arthritis” and “insomnia” they’re caused by the same thing, just in a younger population.
  • 64. Unexplained or Chronic Pain
    • Most of the patients who don’t sleep normally develop chronic pain over time. Different places for different people. Old football injuries start to hurt again.
    • Areas of prior injury may need more maintenance to get better?
    • All of your elderly patients with knee or hip pain deserve a 6 month trial of a D 60-80 to see if their pain goes away before the joint is replaced.
  • 65. Depression and “Bipolar”
    • Depression means less, or interrupted REM sleep in most people.
    • SSRI’s prevent or suppress REM sleep.
    • We give a drug that keeps the REM sleep from coming back insuring that the sleep and the mood never return to normal
    • Antipsychotic medications that block dopamine block the chemical that runs sleep, further guaranteeing that the patient’s sleep will never return to normal.
    • All of your women with post partum depression have D deficiency and a sleep disorder. Treat that first. Get the level above 60 to fix the sleep. The restorative sleep fixes the mood.
  • 66. Why do women get fat after babies?
    • Babies suck up their D.
    • They never make up that deficit and go on to have their uterus and gallbladder removed.
    • Get the D back to normal after every pregnancy.
    • Moms that sleep are happy moms.
    • Babies that sleep are happy babies.
    • Women who are infertile usually have low D’s and don’t sleep either. Same for the men.
  • 67. Babies and Children
    • If the baby doesn’t sleep then the baby is D deficient also.
    • Most of the babies born in the last 20 years were born D deficient.
    • Normal babies sleep 18 hours a day. They develop their brains while they sleep. Babies who do not sleep don’t develop their brains normally.
    • Four things seen in the last 25 years in D deficient kids: Asthma, Allergies, ADD, Autism . WBC effects and sleep effects explain all four of these.
    • Kids who do not have normal restorative sleep at night cannot pay attention in class, “ADD”.
    • They also get frequent respiratory infections, tubes in the ears, etc.
  • 68. Babies and Children
    • American Academy of Pediatrics recommends all babies receive 400 IU of D per day. It is not in the breast milk, even if mom takes supplement. Formula fed babies have it in formula, breast fed babies need it daily in dropper form.
    • www.vitamindcouncil.org has pediatric dosing recommendations by weight for children. Always watch their sleep. Always follow their levels every 3 months for the first 1-2 years until you’re sure of the dosing for each child.
    • The D level for children should be the same as for adults 60-80. When they wake up before you do and are happy and playful and interested and want to learn their sleep is normal.
    • When asked, all children say their sleep is “fine”, ask the mom if she has to wake her up several times in the morning for school.
    • All children who can’t fall asleep have very low D’s.
  • 69. Summary
    • “ I just can’t believe that every disease I see is due to vitamin D deficiency.”
    • You and I are not treating tuberculosis, or typhoid, or polio, or diphtheria, or cholera, or syphilis.
    • Also, the populations of central Africa are not suffering from vitamin D deficiency, you’re just not in practice there.
    • Medicine has made remarkable advances in the last 100 years. You and I spend our time treating what’s left.
    • It’s true that we have many medications for things that are caused by a hormone deficiency that is now epidemic in our country.
  • 70. Summary
    • The drug companies only make drugs for things that are common. The fact that so many diseases due to D deficiency are common, that’s our mistake .
    • This is our responsibility. Even though we’re late, we do know what this chemical does, and we have it in our hands to use.
    • Read the 100’s of articles that have already been written and try it in yourself and your patients.
    • There is no “safe dose that I can take without measuring my level” . Would you dabble with thyroid hormone to see if you felt a little better without measuring your level?
    • Treat it like a hormone, that’s what it is.
  • 71. Summary
    • The right test is D25OH, not D1, 25 OH .
    • Medicare pays for it 4 times per year: ICD 9 268.9
    • D2 and D3 are not really the same. Wallmart, and Sam’s Club carry 5,000 IU D3 pills. Sam’s is the cheapest and most dependable. You don’t need D2 to get a big dose.
    • Start yourself and your patients on whatever dose you feel comfortable with, then measure a level again in 2-3 months. Pay attention to whether it’s winter or summer! Once your level doesn’t budge, go up a little on the dose, teach yourself what I learned but don’t go above 80.
    • Get the level to 60-80 ng/ml. Sleep does not get better until then.
    • If the recognized “normal” is 30-100 it can’t hurt to get the level to 60-80. See how you and your patients feel there instead of 15-20.
  • 72. Our healthy vitamin D future