Dermato-Endocrinology

ISSN: 1938-1980 (Online) Journal homepage: www.tandfonline.com/journals/kder20

Evaluation of vitamin D3 intakes up to

15,000 international units/day and serum 25-
hydroxyvitamin D concentrations up to 300 nmol/
L on calcium metabolism in a community setting

S. M. Kimball, N. Mirhosseini & M. F. Holick

To cite this article: S. M. Kimball, N. Mirhosseini & M. F. Holick (2017) Evaluation of vitamin D3
intakes up to 15,000 international units/day and serum 25-hydroxyvitamin D concentrations
up to 300 nmol/L on calcium metabolism in a community setting, Dermato-Endocrinology, 9:1,
e1300213, DOI: 10.1080/19381980.2017.1300213

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Mirhosseini, and M. F. Holick

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DERMATO-ENDOCRINOLOGY
2018, VOL. 9, NO. 1, e1300213 (10 pages)
https://doi.org/10.1080/19381980.2017.1300213

RESEARCH PAPER/REPORT

Evaluation of vitamin D3 intakes up to 15,000 international units/day and serum

25-hydroxyvitamin D concentrations up to 300 nmol/L on calcium metabolism in a
community setting
S. M. Kimballa, N. Mirhosseinia, and M. F. Holick b

a
Pure North S’Energy Foundation, Calgary, AB, Canada; bBoston University Medical Center, Boston, MA, USA

ABSTRACT ARTICLE HISTORY

Supplementation by the general public with vitamin D at doses above the Tolerable Upper Received 19 December 2016
Level of Intake (UL) is becoming quite common. The objective of the current analysis was to Accepted 23 February 2017
characterize the effect of vitamin D supplementation at doses up to 15,000 IU/d in a KEYWORDS
community-based program on vitamin D status, calcium homeostasis as well as on kidney, 25-hydroxyvitamin D; C
liver and immune function. We evaluated data collected for 3,882 participants in a community reactive protein;
program for whom there were blood measurements at program entry and at follow-up within hypercalcemia;
6–18 months between 2013 and 2015. Participants were supplemented with a wide range of hypervitaminosis D;
vitamin D doses (1,000 – 15,000 IU/d) aimed at achieving serum 25-hydroxyvitamin D [25(OH) inflammation; serum calcium;
D] levels of at least 100 nmol/L. Serum 25(OH)D concentrations up to 300 nmol/L were supplementation; toxicity;
achieved without perturbation of calcium homeostasis or incidence of toxicity. Hypercalcemia vitamin D
and hypercalciuria were not related to an increase in 25(OH)D concentrations nor vitamin D ISRCTN
dose. To achieve serum 25(OH)D levels >100 nmol/L on average, required vitamin D intakes 18397898
of 6,000 IU/d for normal Body Mass Index (BMI), 7,000 IU/d for overweight and 8,000 IU/d for
obese. Doses of vitamin D in excess of 6,000 IU/d were required to achieve serum 25(OH)D
concentrations above 100 nmol/L, especially in individuals who were overweight or obese
without any evidence of toxicity. Serum 25(OH)D concentrations up to 300 nmol/L were found
to be safe.

Introduction
including autoimmune disorders, diabetes, cardiovas-
Evidence suggests that optimal vitamin D status cular disease and cancer.6
reduces the risk for a long list of chronic health condi- Logically, the criteria for determining nutrient
tions. However, the composite literature is often intake requirements should be based on the actual
inconsistent and confusing and has led to heated function of the nutrient, not disease prevention. The
debates about optimal vitamin D status. To confuse challenges for setting an intake requirement for vita-
matters more, there is a wealth of expert opinions to min D are based in physiology. Three separate lines of
support both sides of the argument.1-4 evidence, encompassing i) the compensatory mecha-
Nearly every cell in the body has a vitamin D recep- nism for vitamin D’s role in calcium homeostasis, ii)
tor and vitamin D is necessary for a myriad of cellular natural ancestral levels that can be obtained through
functions.5 In fact, low vitamin D status reduces the unhindered sun exposure and iii) levels required for
capacity of most tissues to carry out normal physio- breastmilk to contain adequate vitamin D for the
logic functions. Vitamin D is necessary for skeletal, nursing infant, converge to establish an optimal vita-
health, immune, developmental, and cardiovascular min D status.7,8 Heaney concluded that a 25(OH)D
health and to protect against cancer. As a result, low level of 100 to 130 nmol/L is the status best suited for
vitamin D status increases the risk of several diseases normal physiology.4 The safety of serum 25(OH)D

CONTACT M. F. Holick [email protected] Boston University Medical Center, 85 East Newton St. M-1013, Boston, MA 02118, USA.
Supplemental data for this article can be accessed on the publisher’s website.
© 2018 S. M. Kimball, N. Mirhosseini, and M. F. Holick. Published with license by Taylor & Francis
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/
4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in
any way.
e1300213-2 S. M. KIMBALL ET AL.

levels as high as 500 nmol/L has been reported9-11 and vitamin D3 supplementation required to achieve a
recently confirmed in large community-based serum 25(OH)D above 100 nmol/L is on average
samples.12,13 5,000 IU/d9,17-19 and 2–3 times more for overweight
An adult in a bathing suit exposed to an amount of and obese individuals.11,18
sunlight that causes a slight pinkness to the skin Natural levels of 25(OH)D achieved through sun
24 hours later (1 minimal erythemal dose; MED) is exposure in Maasai herdsman that is in the range of
equivalent to ingesting approximately 15,000 IUs of 100–150 nmol/l can also be achieved with oral intake
vitamin D.14-16 However physicians remain concerned of 5,000–10,000 IU/d.4,17 The Endocrine Society Prac-
with intakes above 4,000 IU/d. The Institute of Medi- tice Guidelines recommend that up to 10,000 IUs daily
cine (IOM) established 4,000 IU/d as the tolerable was safe for adults.8,14 This is in contrast to the recom-
upper level of intake (the level unlikely to cause harm mended UL at 4,000 IU/d from the IOM. Thus the
in almost all adults). Recent studies demonstrate that safety profile for supplemental intakes above 4,000
vitamin D supplement use has increased, whether IU/d remains uncertain. For an individual with a high
due to self-selected or physician-directed dosing, and body mass index (BMI), doses over 10,000 IU/d may
25(OH)D levels above 150 nmol/L have increased by be necessary to achieve a 25(OH)D of at least
200% over 10 y.12-13 In addition, the amount of 100 nmol/L. The present analysis evaluated vitamin D

Figure 1. Response to vitamin D supplementation based on baseline 25(OH)D concentrations and BMI (a) Normal BMI, (b) Overweight;
and (c) Obese.
 DERMATO-ENDOCRINOLOGY e1300213-3

supplementation at intakes up to 15,000 IU/d in a of overweight, and 65.5% of obese participants

community setting on various parameters of calcium achieved levels above 100 nmol/L. Vitamin D3 intakes
metabolism and potential toxicity. of at least 6,000 IU/d were required for those with a
normal BMI to achieve serum 25(OH)D concentra-
tions above 100 nmol/L, or 7,000 IU/d and 8,000 IU/d
Results
for overweight and obese, respectively. Seventy per-
Anonymized data from 3,882 new participants were cent of participants reached serum 25(OH)D levels
available with follow-up, on average one year later, above 100 nmol/L at follow-up and 45% above
between 2012 and 2015 and included in this analysis. 125 nmol/L.
The mean age of participants was 59.6 § 14.8 y and There was a subgroup of participants (n D 285) that
59.5% were female. Less than 1% of the participants reported substantial intakes of vitamin D supplements
had a BMI in the underweight range, 35.5% had a nor- (> 4,000 IU/d) that did not experience an increase in
mal BMI, 37.0% were overweight and 27.5% were serum 25(OH)D concentrations. We investigated
obese (18.2% obese I, 5.8% obese II, 3.5% extreme whether BMI was a contributor: 36.5% were within a
obese). normal BMI, 34.0% were overweight, and 27.9% were
At entry to the program (baseline) 55% of partici- obese. Conditions that could cause intestinal absorp-
pants reported taking some vitamin D. The average tion [including Crohn’s disease, celiac disease, inflam-
dose of vitamin D supplements increased from 2,106 § matory bowel disease (IBD), irritable bowel syndrome
2,471 IU/d at baseline to 6,767 § 3,588 IU/d at follow- (IBS), ulcerative colitis, gastrointestinal esophageal
up (n D 2,339). Overall, mean serum 25(OH)D con- reflux disease (GERD)] were present in 38% of these
centrations increased from 87 § 28 nmol/L to 126 § participants, which increased to 60% of the 285 partic-
39 nmol/L (paired t, p < 0.001). ipants when we included whether participants
Serum 25(OH)D concentrations were influenced by reported stomach issues (including bloating, stomach
vitamin D dose in a BMI-dependent manner. Partici- pain, indigestion, upset stomach).
pants with normal BMI and an average vitamin D Mean serum calcium concentrations did not differ
intake of 6,100 IU/d had a mean increase in serum between baseline and follow-up (Table 1). There were
25(OH)D levels from 92 § 29 to 131 § 40 nmol/L 47 participants (1.2%) who presented with hypercalce-
(p < 0.001). Dose-response was also influenced by mia at baseline and 41 participants (1.3%) at follow-
baseline 25(OH)D concentrations for all BMI groups up. Of those, 20 participants were new cases of hyper-
such that individuals with higher baseline 25(OH)D calcemia at follow-up (Supplemental Table 1). The
concentrations experienced a blunted response to the majority of participants found to have a mildly ele-
same vitamin D dose as compared with someone with vated serum calcium level were those who had serum
lower baseline 25(OH)D concentrations (Fig. 1). In 25(OH)D concentrations of 50–100 nmol/L (Table 2).
normal weight participants who were vitamin D-defi- Furthermore it was found that hypercalcemia or
cient at baseline, <50 nmol/L, the response to an aver- hypercalciuria was more often observed in participants
age intake of 7,670 IU/d was substantially greater with who had a serum 25(OH)D level (< 100 nmol/L)
serum 25(OH)D concentrations increased from 38 § (Table 2).
8 nmol/L to 103 § 37 nmol/L (p < 0.001). The Regression analyses revealed that when other varia-
response to vitamin D supplementation was less with bles were taken into account (including age, sex, BMI
increased BMI in a step-wise manner such that obese and baseline levels) serum 25(OH)D and vitamin D
individuals had lower mean 25(OH)D concentrations dose were negative predictors of serum calcium
(118 § 38 nmol/L) than overweight (126 § 38 nmol/L) (Table 3).
who had lower levels than normal BMI (131 § To investigate the effect of vitamin D supplementa-
40 nmol/L) at follow-up, despite higher vitamin D tion on the development of hypercalcemia, we investi-
intakes (Table 1). gated the probable cause of the newly developed
A goal of the community-based program was to hypercalcemia on a case-by-case basis. Of the 20 cases,
achieve a 25(OH)D concentration of at least 6 were no longer hypercalcemic upon re-testing. There
100 nmol/L. At baseline 18.4% of participants met this were 2 cases of hyperparathyroidism, one who was
target and at follow-up 76.3% of normal BMI, 74.5% being treated by an endocrinologist and one who was
 e1300213-4
S. M. KIMBALL ET AL.

Table 1. Comparison of measurements between baseline and follow-up within categories of Body Mass Index (BMI).
Normal (BMI < 25) Overweight (BMI D 25–30) Obese (BMI  30)

Baseline vs. Baseline vs. Baseline vs.

N Baseline Follow-up Follow-up N Baseline Follow-up Follow-up N Baseline Follow-up Follow-up

BMI (kg/m2) 1398 22.4 § 1.9 22.9 § 2.5 <0.001 1437 27.3 § 1.4 27.6 § 1.9 <0.001 1047 34.4 § 4 34.5 § 4.4 0.02
Vitamin D dose (IU/d) 1225 2232 § 2463 6090 § 3221 <0.001 1246 2111 § 2391 6751 § 3520 <0.001 928 1932 § 2578 7652 § 4026 <0.001
Serum 25(OH)D (nmol/L) 1366 91.5 § 29 131 § 40 <0.001 1446 87.2 § 28 126 § 38 <0.001 1053 80 § 26 118 § 38 <0.001
Serum Calcium (mmol/L) 1350 2.40 § 0.08 2.39 § 0.08 0.08 1413 2.40 § 0.09 2.39 § 0.09 0.3 1045 2.39 § 0.09 2.39 § 0.09 0.2
Serum PTH (ng/L) 453 35.7 § 14 35.2 § 14 0.4 494 37.8 § 14 36.6 § 14.5 0.06 327 41.9 § 16.4 39.3 § 15 0.001
Serum hs-CRP (mg/L) 1122 1.10 § 1.4 1.33 § 1.4 <0.001 1155 1.63 § 1.7 1.86 § 1.6 <0.001 773 2.68 § 2.2 2.86 § 2.2 <0.001
Serum Creatinine (mmol/L) 1193 77.6 § 18.7 78.2 § 16.7 <0.001 1243 82 § 19 82.8 § 20 0.01 915 82.5 § 32 81.9 § 23 0.8
Estimated GFR (mL/min) 1193 78.5 § 20 76.7 § 18 <0.001 1243 75.6 § 16.7 74.5 § 17.3 <0.001 915 75 § 17.5 74.7 § 17.5 0.1
Serum ALT (U/L) 1191 20.6 § 16.6 18.3 § 11 <0.001 1246 24.7 § 19.3 22.2 § 15.8 <0.001 907 27.3 § 22 24.5 § 16 <0.001
Serum GGT (U/L) 1191 24.7 § 37.6 20.6 § 20.8 <0.001 1246 30.7 § 36 27.5 § 31.6 <0.001 907 35.4 § 28 31.6 § 29 <0.001
Urine Calcium: Creatinine Ratio 190 0.124 § 0.08 0.131 § 0.08 0.2 193 0.108 § 0.07 0.129 § 0.07 <0.001 135 0.096 § 0.07 0.111 § 0.07 0.01
(mg/mg)

PTH: Parathyroid hormone; hs-CRP: high-sensitivity C reactive protein; GFR: Glomerular filtration rate; ALT: Alanine aminotransferase; GGT: Gamma glutamyltransferase
 DERMATO-ENDOCRINOLOGY e1300213-5

Table 2. Calcium measures, serum PTH and vitamin D supplementation dose at follow-up based on categories of serum 25(OH)D
concentration.
Serum 25(OH)D (nmol/L)

50–100 100–150 150–200 200–250 250–300

N (blood) 973 1744 673 98 14

Vitamin D dose (IU/d) 6086 § 4002 7016 § 3670 7228 § 3315 8310 § 3505 7533 § 3136
25(OH)D (nmol/L) 80 § 13 123 § 14 169 § 14 218 § 14 264 § 12
PTH (ng/L) 40.8 § 16 37.7 § 15 34.9 § 14 31.5 § 12 33.3 § 13
Albumin-corrected calcium (mmol/L) 2.32 § 0.08 2.34 § 0.08 2.34 § 0.08 2.33 § 0.08 2.36 § 0.06
Hypercalcemia (%) 1.7 1.4 0.8 1 0
N of Hypercalcemia 12 20 5 1 0
N (urine) 97 257 117 23 3
Urinary calcium:creatinine ratio (mg/mg) 0.099 § 0.06 0.132 § 0.07 0.129 § 0.07 0.133 § 0.08 0.106 § 0.02
Hypercalciuria (%) 1.2 10.9 4.4 1.2 0
N of Hypercalciuria 6 54 22 6 0

% of total

referred to their general physician for care. Four cases participants, PTH levels were not obtained on both
involved participants with suboptimal 25(OH)D val- visits and participants did not return to the clinic for
ues at baseline that were increased significantly at fol- further follow-up by the time this analyses was con-
low-up (55 § 26 to 135 § 52 nmol/L) in whom PTH ducted. Overall, serum 25(OH)D concentrations
levels were decreased. In one participant serum 25 increased modestly (from 94 § 4 to 119 § 18 nmol/L)
(OH)D concentrations rose from 115 nmol/L at base- with an increase in serum calcium levels (from 2.48 §
line to 185 nmol/L at follow-up with a serum calcium 0.04 to 2.58 § 0.02 mmol/L).
of 2.56 or 0.01 mmol/L outside the reference range. In Urine calcium and creatinine measurements were
this participant PTH values did not change between available for 521 participants. Hypercalciuria (urine
baseline and follow-up and were within reference calcium:creatinine  0.2 mg/mg) was detected in
ranges (41 and 42 ng/L, respectively). In one partici- 17.6% of participants at baseline. There was virtually
pant serum 25(OH)D concentrations increased from no increase in the prevalence of hypercalciuria at fol-
125 to 258 nmol/L with serum calcium levels increas- low-up (17.7%). Regression analysis revealed no effect
ing from 2.48 to 2.59 mmol/L and PTH levels of serum 25(OH)D or vitamin D dose on urine cal-
decreased from 54 to 47 ng/L. Two participants who cium:creatinine ratios when age, sex, BMI and baseline
had serum calcium levels within the reference range at levels were accounted for (Table 3).
baseline experienced decreases in 25(OH)D concen- We examined the 52 new cases of hypercalciuria at
trations (from 85 and 150 nmol/L to 73 and follow-up in detail (Supplemental Table 2). There
108 nmol/L, respectively) and both had a follow-up were 9 cases in which serum 25(OH)D concentrations
serum calcium of 2.67 mmol/L. For the remaining 4 decreased between baseline and follow-up. None of

Table 3. Predictors of Serum Calcium and Urinary Calcium: Creatinine Ratio, using Multiple Linear Regression Model.
Dependent variable at follow-up Predictors B Standardized Coefficients (b) P-Value 95% Confidence Interval

Serum calcium (mmol/L) Model (R D 0.35)

2

Age 0.001 0.11 <0.001 0–0.001

Gender ¡0.006 ¡0.04 0.01 ¡0.011–0.001
Calcium baseline 0.49 0.53 <0.001 0.458–0.517
Serum 25(OH)D (nmol/L) ¡9.07E-5 ¡0.03 0.04 0.000–0.000
Vitamin D dose (IU/d) ¡8.36E-7 ¡0.04 0.02 0.000–0.000
BMI (kg/m2) 0.001 0.04 0.01 0–0.001
Urine calcium: creatinine ratio Model (R2 D 0.16)
(mg/mg)
Age 0 0.09 0.05 0–0.001
Gender ¡0.01 ¡0.08 0.07 ¡0.024–0.001
Calcium baseline (mmol/L) 0.06 0.07 0.1 ¡0.013–0.135
Serum 25(OH)D (nmol/L) 0 0.07 0.09 0.000–0.000
Vitamin D dose (IU/d) 1.35E-7 0.006 0.8 0.000–0.000
BMI (kg/m2) ¡0.001 ¡0.07 0.1 ¡0.002–0.000
Urine calcium:creatinine Baseline 0.35 0.34 <0.001 0.261–0.433
e1300213-6 S. M. KIMBALL ET AL.

the cases were associated with hypercalcemia or a observed when the blood level is above 375 nmol/L.11
reduction in PTH values. Our data are consistent with this recommendation.
We also examined the participants who were Some of the participants achieved serum 25(OH)D
hypercalciuric at baseline and who had a follow-up levels up to 300 nmol/L without any evidence of
urine measurement (n D 67) to determine the effect of hypercalciuria or hypercalcemia. Suppression of the
vitamin D supplementation on the incidence of hyper- serum PTH concentration is the most sensitive indica-
calciuria. Urine calcium:creatinine ratios were tor of a perturbation in calcium homeostasis, and thus
decreased after vitamin D supplementation (from an indication of an adverse effect of vitamin D supple-
0.255 § 0.54 to 0.175 § 0.077). At follow-up 67% mentation. There was no significant reduction in the
were no longer hypercalciuric while on vitamin D PTH levels in those participants who had the highest
supplementation. intakes of vitamin D and achieved blood levels of
None of the participants developed any biochemical 25(OH)D above 250 nmol/L.
evidence for vitamin D toxicity i.e. hypercalcemia Higher serum 25(OH)D have been found in 2 other
associated with a suppressed PTH level. community-based studies.12,13 Dudenkov et al. report
Biochemical markers for kidney function (serum an increase in the incidence of serum 25(OH)D con-
creatinine and eGFR) and liver function (ALT and centrations above 125 nmol/L (50 ng/mL) in Rochester
GGT) remained within the reference ranges (Table 1). over 10 y from 9 to 233 cases per 100,000 person-years.
Kidney and liver function tests were not influenced by Of the 20,308 measurements they found 8.4% were
serum 25(OH)D concentrations (Supplemental above 125 nmol/L.12 Similarly, we found that only 45%
Table 3).There was a weak negative correlation of participants achieved a serum 25(OH)D above
between 25(OH)D and hs-CRP (R2 D 0.003, y D 125 nmol/L despite average intakes of vitamin D at
¡0.002x C 2.29, p D 0.001). 7,000 IU/d. The serum 25(OH)D concentrations were
not related with serum calcium or an increased risk of
hypercalcemia,12 similar to what we observed. Perez-
Discussion
Barrios et al. report that 11.1% of 25,567 measurements
Naturally acquired vitamin D from whole body sun made over 6 y from hospital samples were found to
exposure (1 MED) is equivalent to ingesting »15,000 have 25(OH)D concentrations over 160 nmol/L and
IU vitamin D supplement.14,16 Equatorial tribes that less than 4% of these cases were associated with
exposed to sunlight on a daily basis at the equator hypercalcemia. Unfortunately, the authors did not
achieve an average 25(OH)D level of 115 nmol/L8. report the prevalence of hypercalcemia in the samples
The IOM states that the safety profile for supplemen- with serum 25(OH)D below 160 nmol/L13.
tal intakes above 4,000 IUs daily and blood levels of As expected,20 when baseline serum 25(OH)D lev-
25(OH)D above 75 nmol/L is uncertain and above els were below 50 nmol/L the increase in 25(OH)D
125 nmol/L may increase mortality.1 The Endocrine was much more robust with the mean increase of
Society concluded that ingestion of up to 10,000 IUs 60 nmol/L for those participants who ingested 4,000–
daily was not associated with any significant alteration 8,000 IU/d of vitamin D. In those with higher baseline
in calcium metabolism and recommended that circu- values, the increase in 25(OH)D was much lower
lating levels of 25(OH)D to be at least 75 nmol/L with (mean increase of 8–15 nmol/L) for participants who
a preferred range of 100–150 nmol/L for maximum took the same amount of vitamin D. The increase also
bone and muscle health. We observed that the amount depended on BMI as previously reported.18,21 BMI
of vitamin D required to achieve serum 25(OH)D was found to be the most significant factor for the
concentrations of at least 100 nmol/L, particularly in vitamin D dose-response. The higher doses of vitamin
overweight and obese individuals was between 6,000– D needed for overweight and obese to achieve the
8,000 IU/d on average. Some of the participants were same serum 25(OH)D concentrations as normal BMI
taking as much as 15,000 IUs of vitamin D daily with- may be due to several factors in addition to the poten-
out any untoward toxicity. tial for vitamin D to be distributed to adipose tissue.
The Endocrine Society recommended that a blood Obesity is associated with chronic inflammation in
level of 25(OH)D up to 250 nmol/L was not associated metabolic tissues.22 Vitamin D is a potent immuno-
with toxicity and that vitamin D toxicity is usually modulator and anti-inflammatory agent. The constant
 DERMATO-ENDOCRINOLOGY e1300213-7

state of low-grade inflammation characteristic of obe- program adherence and thus would allow us a greater
sity may increase requirements for vitamin D. ability to detect hypercalcemia related to vitamin D
Another consideration is the role of the gut micro- intake. Among the strengths of the current analyses
biota. Vitamin D has been found to modulate the gut are the large community-based population, nearly
microbiome in the upper gastrointestinal tract. Distur- 4,000 participants, and access to all follow-up assess-
bances in the microbiome have been suggested to play ments that were performed, including any related to
a role in the pathogenesis of metabolic disorders and probably vitamin D toxicity.
the composition of gut microbes is strongly influenced Vitamin D may play a key role in health optimiza-
by diet.23 Further, gut microbes influence gut motility tion and prevention of chronic disease. A considerable
and absorption of nutrients, thus an unbalanced amount of literature suggests that serum 25(OH)D
microbiome may result in reduced absorption of vita- concentrations around 100–150 nmol/L are ideal for
min D. There is also the role of the microbiome in physiology4 and disease prevention.30 A statistical
development and maintenance of the immune sys- error has been reported and confirmed independently
tem.24 A disruption of the microbiome that alters that suggests the correct Recommended Daily Allow-
immune function may also alter immune cell require- ance (RDA) is »7,000 IU/d4,19. However, there
ments or use of vitamin D. remains considerable public debate among experts.
We found that 9% of participants reported an intake Ultimately, the decision to take vitamin D supple-
of vitamin D of at least 1,000 IU/d did not experience ments is up to the individual. While the present study
an increase in 25(OH)D concentrations; 90% of does not address what is an optimal vitamin D status,
these were taking > 4,000 IU/d and up to 16,000 IU/d. it does confirm the safety of serum 25(OH)D concen-
There are several possible reasons for this. The most trations up to 300 nmol/L and intakes of vitamin D up
obvious is non-compliance. However, the effect of obe- to 15,000 IU/d. Further, the results presented here
sity must be considered with 62% of these participants demonstrate a variable response to vitamin D
being overweight and obese. The response to a given intake and suggest that intakes of 6,000–8,000 IU/d
dose of vitamin D has been found to be 2–3 times less are required to achieve serum 25(OH)D above
in overweight and obese individuals in comparison 100 nmol/L.
with individuals with a normal BMI.18 Further, malab-
sorption may play a significant role. Sixty per cent of Methods and materials
these participants reported stomach issues such as IBD
Intervention
and Crohn’s disease in the present analysis. Twenty
million Canadians have digestive disorders.25 A recent This study was a database analysis of a wellness pro-
meta-analysis reported that patients with IBD have a gram focused on the prevention of chronic diseases.
64% higher odds of being vitamin D deficient.26 In The program provides lifestyle advice, education and
addition, bone disease is present in nearly half of optimization of nutrition through the use of research-
patients studied with Celiac disease27 and IBD.28 In based nutritional supplements, with a focus on achiev-
patients with Crohn’s disease the ability to absorb a ing 25(OH)D levels above 100 nmol/L. Supplement
dose of vitamin D was found to be 30% lower than in recommendations are based on analysis of each partic-
healthy controls.29 The role of gastrointestinal health ipant’s biometric measurements, blood results and
in vitamin and mineral absorption is of concern. clinical intake data. Health care professionals review
This study has several limitations including the ret- and explain blood work results with the participant
rospective design, bias introduced from self-reported and, based on their clinical knowledge and nutrient
vitamin D intakes, and lack of complete data for all expertise, make recommendations accordingly. Each
participants (e.g. urine calcium: creatinine ratios were participant is treated as an individual and a treatment
available for half of participants). Another limitation plan developed to meet that individual’s nutrient
includes the potential for selection bias – we were only requirements. All participants were encouraged to
able to assess participants that remained in the pro- achieve a 25(OH)D level of at least 100 nmol/L and
gram and had follow-up visits. However, we would individual vitamin D doses were adjusted accordingly.
expect that those remaining in the program would This clinical program has been registered with
have higher serum 25(OH)D values because of ISRCTN18397898. The ISRCTN is a registry and a
e1300213-8 S. M. KIMBALL ET AL.

database containing essential information to describe completed using the first tube of blood collected from
a study deemed important by the World Health Orga- each blood draw. Serum hs-CRP and PTH were mea-
nization (WHO), International Clinical Trials Registry sured with immuno-turbidimetric and ELISA meth-
Platform (ICTRP), and the International Committee ods, respectively (inter-assay CVs were both 2.5%).
of Medical Journal Editors (ICMJE). Serum ALT and GGT were measured on the Beckman
Coulter, using enzymatic method with the inter-assay
Database CVs of 4.3% and 2.9%, respectively. Serum creatinine
was measured using the Jaffe method with the inter-
Anonymized data from the program were assessed
assay CV of 1.1%. Estimated GFR was calculated using
for all new participants who entered the program
following equation: eGFR D 186 £ (creatinine/
between 2012 and 2015 consented for the use of their
88.4)¡1.154 £ (age)¡0.203 £ (0.742 if female) £ (1.21 if
anonymized data for research and who had follow-
black).31 All laboratory testing was validated according
up within a 6–18 month period after their first visit
to ongoing externally provided accreditation test sam-
(n D 3,882). We selected a period when all of the
ples. Values are presented as mean § standard
biochemical results were obtained from one labora-
deviation.
tory, Doctors’ Data (St. Charles, IL). The majority of
participants in the program were healthy adults,
Categories
without any history of hyperparathyroidism, granulo-
matous diseases, hypercalcemia and chronic kidney Participants were categorized according to their gen-
diseases or on any medications that could influence der, age, BMI and serum 25(OH)D status. Serum
calcium and vitamin D metabolism. Parathyroid 25(OH)D categories were defined a priori in 50 nmol/
Hormone (PTH) concentrations were evaluated up L increments: < 50, 51–100, 101–150, 151–200, 201–
until January of 2014, after which only participants 250, 251–300, > 300 nmol/L. Vitamin D intake cate-
that presented with high serum calcium values had gories were defined as: <1,000 IU/d, 1,000-<4,000
PTH evaluated. All participants had provided written, IU/d, 4,000-<8,000 IU/d, 8,000-<12,000 IU/d and 
informed consent to permit anonymous analysis of 12,000 IU/d. The reference range for serum calcium,
their data for research. 2.10 – 2.55 mmol/L (8.4 – 10.3 mg/dL), had been
established by the laboratory using standard proce-
Measurements dures.32 Hypercalcemia was defined as serum calcium
concentration  2.55 mmol/L (10.3 mg/dL). Hyper-
Demographic information was obtained for all partici-
calciuria was defined as urine calcium: creatinine ratio
pants. Body mass index (BMI) was calculated dividing
above 0.2. The reference interval for urine calcium:
body weight (kg) by square height (m2). All sample
creatinine was < 0.14 and between 0.14 and 0.2 was
preparation and biochemical measurements were per-
considered borderline.33
formed by Doctor’s Data Laboratory (St. Charles, IL),
a fully accredited laboratory. Four different categories
Statistical analyses
of biochemical parameters involving vitamin D safety
were evaluated, including; calcium homeostasis Data were analyzed using SPSS version 23 (SPSS
[serum calcium, 25(OH)D, PTH and urinary calcium: Inc., Chicago, IL). Descriptive analysis was per-
creatinine ratio], inflammation [high-sensitivity C- formed to establish the distribution of categorical
reactive protein (hs-CRP)], liver function [Alanine data. Since the data was not normally distributed,
Amino-Transferase (ALT), Gamma Glutamyl Trans- non-parametric tests were applied. Wilcoxon Signed
ferase (GGT)] and kidney function [estimated Glo- Rank Test was performed to evaluate changes in
merular Filtration Rate (eGFR), serum creatinine]. different variables over follow-up period. Mann
Serum 25(OH)D was measured using Liquid Chroma- Whitney U-test and Kruskal-Wallis test were done
tography and tandem Mass Spectrometry (LC/MS- to compare means according to different categorical
MS) with the inter-assay CV of 2.4%. Serum calcium groups including age, gender, BMI and serum 25
and albumin concentrations were measured using (OH)D status. Multiple linear regression was per-
spectrophotometric method. To avoid any affect due formed to determine the predictors of vitamin D
to hemoconcentration, all calcium measures were status, PTH levels, hypercalcemia, hypercalciuria,
 DERMATO-ENDOCRINOLOGY e1300213-9

inflammation, liver and kidney function. Signifi- randomized double-blind clinical trial. Plos One 2013; 8
cance was defined as p < 0.05. (3):e58725; PMID:23527013; https://doi.org/10.1371/
journal.pone.0058725
[6] Holick MF. Vitamin D: importance in the prevention of
Ethics cancers, type 1 diabetes, heart disease, and osteoporosis.
Am J Clin Nutr 2004; 79(3):362-71; PMID:14985208
This study was performed using secondary data that
[7] Hollis BW, Johnson D, Hulsey TC, Ebeling M, Wagner
was anonymized (participants were identified by a CL. Vitamin D supplementation during pregnancy: dou-
randomly generated 36-digit anumeric code only) and ble-blind, randomized clinical trial of safety and effective-
did not require ethics board approval. ness. J Bone Miner Res 2011; 26(12):3001; https://doi.
org/10.1002/jbmr.537
Disclosure of potential conflicts of interest [8] Luxwolda MF, Kuipers RS, Kema IP, van der Veer E,
Dijck-Brouwer DA, Muskiet FA. Vitamin D status indi-
The authors report no conflict of interest. No financial interest cators in indigenous populations in East Africa. Eur J
or benefit has arisen from the direct application of our Nutr 2013; 52(3):1115-25; PMID:22878781; https://doi.
research. S.M.K. and N.M. are used by the Pure North S’Energy org/10.1007/s00394-012-0421-6
Foundation. [9] Vieth R. Vitamin D supplementation, 25-hydroxyvitamin
D concentrations, and safety. Am J Clin Nutr 1999; 69
(5):842-56; PMID:10232622
Acknowledgments
[10] Hathcock JN, Shao A, Vieth R, Heaney R. Risk assess-
The authors would like to thank Mr. Ken Fyie for his work in ment for vitamin D. Am J Clin Nutr 2007; 85:6-18;
constructing the data set and Dr. Paul Veugelers for his com- PMID:17209171
ments on the manuscript. [11] Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon
CM, Hanley DA, Heaney RP, Murad MH, Weaver CM
and Endocrine Society. Evaluation, treatment, and pre-
Funding
vention of vitamin D deficiency: an Endocrine Society
There was no funding provided directly for this work. Salaried clinical practice guideline. J Clin Endocrinol Metab 2011;
employees of Pure North S’Energy Foundation, a not for profit 96(7):1911-30; PMID:21646368; https://doi.org/10.1210/
organization, designed the study, performed data analyses and jc.2011-0385
wrote the manuscript in collaboration with Dr. Michael F. [12] Dudenkov DV, Yawn BP, Oberhelman SS, Fischer
Holick from Boston University Medical Center, who partici- PhR, Singh RJ, Cha SS, Maxson JA, Quigg SM,
pated in the analysis and writing of the manuscript. Thacher TD. Changing Incidence of Serum 25-
Hydroxyvitamin D Values Above 50 ng/mL: A 10-
Year Population-Based Study. Mayo Clin Proc 2015;
ORCID 90(5):577-86; PMID:25939935; https://doi.org/10.1016/
M. F. Holick http://orcid.org/0000-0001-6023-9062 j.mayocp.2015.02.012
[13] Perez-Barrios C, Hern
andez-Alvarez E, Blanco-Navarro
I, Perez-Sacristan B, Granado-Lorencio F. Prevalence of
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