Fatigue, Pain, Poor Sleep? It Could Be Vitamin D. | Dr. Gregory Plotnikoff & Dr. Dacre Knight (Ep. 199)

Transcripts are autogenerated and may contain errors

Gregory Plotnikoff: [00:00:00] Greg, if you make the right diagnosis for someone, great. But if you haven't thought about five other biologically plausible explanations for their experience, you're really not a good doctor for them.

Dr. Linda Bluestein: Welcome back, every bendy body to the Bendy Bodies podcast. I'm your host, Dr. Linda Bluestein, the Hypermobility MD, a Mayo Clinic-trained physician dedicated to helping you navigate Ehlers-Danlos syndromes and complex chronic illness. Today, I'm joined by Dr. Dacre Knight, who is not only an expert in EDS, HSD, POTS, and mast cell disorders, but is also joining me as a recurring co-host.

Dr. Knight recently became the medical director of the UVA Ehlers-Danlos Syndromes Center, which is officially partnering with Bendy Bodies. Today's [00:01:00] guest is Dr. Gregory Plotnikoff. Dr. Plotnikoff is such a wealth of knowledge, and today we're going to be focusing specifically on vitamin D. This is such an important topic because so many people have persistent pain, sleep problems, all kinds of problems with their mood, and vitamin D can play a really important role.

As always, this information is for educational purposes only and is not a substitute for personalized medical advice. Stick around until the very end so you don't miss any of our special hypermobility hacks. Here we go. I'm so excited to be here today with Dr. Plotnikoff and of course, again with Dr.

Knight. We're gonna be talking about a ton of things related to vitamin D, and I think Dr. Knight is going to lead us off. 

Dr. Dacre Knight: Yeah. Very excited to have you here, Dr. Plotnikoff. Just to get started today, a- and I know this is something that you have, gone through quite a bit in the past, what... You know, speaking of, all the different, [00:02:00] you know, m- mechanisms of things that can go wrong for someone with EDS and HSD, a lot of things that come up are questions about lab work, blood tests, electrolytes, vitamins, minerals, and things like that, but specifically related to vitamin D.

You know, this is, something that I look at and we test for and discuss with patients. Let us, hear, from, from your e- expertise about, Well, first, so starting, what is vitamin D? why is it considered a, hormone rather than a vitamin? And then, and maybe just a little bit of background for us to, you know, just get this started.

Gregory Plotnikoff: Well, thank you. It's a great honor to be here and, I really... I love the topic of vitamin D because it's the single most cost-effective medical intervention in North America, and is so overlooked. And, so vitamin D is... might be overlooked because someone called it a vitamin, and it really is a hormone [00:03:00] Vitamins are cofactors in enzymatic reactions.

Hormones regulate gene expression, and vitamin D, regulates probably over 2,000 key genes in our body, things related to mood, memory, energy, sleep, bone health, and so much more. And because it's free from the sun on certain days, it really is, so, cost-effective. And you mentioned about kind of the data.

There's, like, over 100,000 articles in the National Library of Medicine on vitamin D-related concerns. So almost any concern that anyone presents with, there has-- there can be a link with vitamin D. And so going by the understanding that fundamentals first, then pharmaceuticals is kind of-- Yeah, vitamin D is just foundational [00:04:00] to anything.

And the problem is we could be really deficient in it, and, and that's the great challenge. You say, "Well, what do you mean by we?" well, if we look at-- did a study of 14,500 Allina Health System employees, 60% were low, 30% were very low, and 6% were profoundly low. And you could say, "Well, that's Minnesota.

You know, you're halfway to the North Pole." But I just pulled an article out today from Karachi, Pakistan, and showing huge percentages, 23% were profoundly low. and so in a sunny country, you can still be vitamin D deficient. Los Angeles, Houston, Tampa is kind of like it's too hot to go outside, so we're inside or [00:05:00] we work long hours indoors or, you know, on and on.

So, so the goal, I'm hoping that people listening will be, will hear today that actually vitamin D is low cost, low toxicity, and represents good, effective self-care. 

Dr. Dacre Knight: Yeah, that's-- that-- And that's what I always turn to too. What are, the easy things we can pull, right? That they may just be sitting right in front of us, that we can, observe this, we can make a change, and it-- and, it can affect some good, positive outcomes.

So, yeah, I, think that, that's definitely been my experience. So-- And I've-- this next question, I've got some ideas of my own, but I certainly, really just wanna hear from your e-experience and you touched on it too a little bit as far as w-why people have load-- low [00:06:00] vitamin Ds who, who live in sunny climates.

but do you see that relate to, symptoms directly based on their climate, based on their occupation, based on their environment and things like that? 

Gregory Plotnikoff: Well, I think particularly for this audience, pain, musculoskeletal pain, stress fractures, s-shin splints, tendinopathies, these are great things.

Now, in the general overall population, it's kinda like it's joint injuries, it's, tibial plateau fractures, it's hip fractures. Much of the research has been done on elderly people and issues around, falls and, joint replacements. But for kinda young, active people and, and with multiple joint, you know, concerns or, actually frank injuries, [00:07:00] vitamin D is still overlooked.

And here's what I feel really passionate about. Back in, the 1980s, I was a, you know, freshly minted doctor, and I was working in clinics where I was seeing people with chronic non-specific musculoskeletal pain, and I was feeling so incompetent. You know, I had done four years of med school and four years of residency, and I felt completely unprepared.

And I said, "Did I miss some lecture? Did I miss something? What, what's going on?" And so back in the, 1980s, one went to a library, and I went through journal after journal trying to find something. I came across an article entitled Hypovitaminosis D Slow to Be Diagnosed in Immigrant Women, and this was the British [00:08:00] Medical Journal, and it was a story about six women who had moved from India to London and then developed these horrible musculoskeletal pain syndromes and fatigue and weakness and, that no one could explain.

One ev- woman even got a, a bone scan looking for cancer, and it looked like she had widely metastatic cancer. And she said, "Ugh, I'm outta here. I'm returning home." Returned home, got better, as if the cancer disappeared, and then returned to London, got worse again. And that raised-- So someone raised the issue, maybe it's vitamin D.

And they found, oh, in these six women, they had really low vitamin D levels and, giving them vitamin D and things resolved. And I said, "Well, these sound like the people I'm seeing in my clinic." That's what I was gonna say. Yeah. And so, so I was, I was working in 14 different languages and, [00:09:00] and, so with immigrants and refugees and I'm just going, "Okay, everyone with unexplained musculoskeletal pain six inch- six months or more, I'm just getting a vitamin D level on them."

And everyone started coming back really low. And, in fact, So I decided, okay, we gotta combine this. So I, published in the first 150 people I saw, showing 100% of African American, 100% of Native American, 100% of East African, 100% of West African, 93% of Southeast Asians, and 80-something percent of, whites were severely vitamin D deficient.

And we found five people with undetectable levels, with one woman who was being treated with high dose neuroleptics because of-- they thought, "Well, this is a somatoform pain disorder." One person [00:10:00] underwent $250,000 worth of... And this is like, this is late, I guess, just saying that late '80s, late '90s dollars.

He got cardiac workup. He got spinal surgery. All his pain never went away. He came to clinic, we measured vitamin D. It was undetectable. We got him on vitamin D replacement, and he is just "It's gone. It's gone." It's just like, Yes. So for everyone listening, please hear my plea. Let me share one story that's unforgettable.

This is a young woman. She's 35 years old, mother of two. She loves working out. One might call her kind of like a gym bunny. She just loved... But for five years, she had progressive musculoskeletal pain and weakness, and she went from doctor to doctor. "Oh, you're anxious. Oh, you need [00:11:00] morphine. Oh, you're depressed."

She's just like, "No, I just wanna get better. don't give me these meds. I just wanna get better. Find out what's going on." Finally, she makes her way to me. Things had gotten so bad that she could barely stand up at the kitchen counter to wash dishes, and her two children were taken away from her. She comes to see me.

I go out to greet her in the waiting room, and she-- and, to shake hands. She pushes herself up and says, "Hi, nice to meet you." I said, "Oh my God, it's vitamin D deficiency." And I swear to you, I kid you not, one bottle of vitamin D, and she got her two kids back 

Dr. Dacre Knight: And she had been going to the gym. Like, she's avid exerciser Well, she had, and until she just got- Until she couldn't, yeah

Gregory Plotnikoff: until just the, pain and the weakness was just too much. And so that's an extreme example. But, you know, I don't want [00:12:00] anyone listening to this, podcast who has any kinds of musculoskeletal pain, please don't, Please have your vitamin D measured. And, why, you know, I published on these 150 patients, with, you know, s- vitamin D deficiency.

It's went on to become one of the most highly cited articles in the history of the Mayo Clinic Proceedings, and its accompanying editorial also is one of the most highly cited articles as well, and it hasn't changed practice. So it's not gonna come from the medical hierarchy. It's gonna come from people saying, "Hey, it's a reasonable part of the differential diagnosis.

I'm a fellow human being. I'm at risk for low vitamin D. Let's measure the vitamin D." And, because [00:13:00] there's, you know, frankly, no, there's no, physical exam for it, aside from someone who's profoundly vitamin D deficient. And, but, you know, so the question is, are you low? How do you know? Can really only know by measurement.

Dosing does not matter, but measurement does. 

Dr. Dacre Knight: Oh, that's great. and that's exactly, again, what I was, referring to earlier. If, you know, if we can get something that's just right there under our noses, and we can, capture that, and we can find a simple, effective, safe treatment, then goodness, it would avoid, extra waste of money or, any other invasive treatments, then, that's exactly what we're going for.

And so y- you said measurement, and I just wanted to pick up on that. What is... I- is, there a specific lab test you, do for that? 

Gregory Plotnikoff: There's only one lab test for that. that's the [00:14:00] 25OH vitamin D. That is the... There are multiple vitamin Ds out there, from the vitamin, pre-vitamin D in our skin to what's circulating in, in our blood that, activate by the liver.

It's then activated by the kidney. so there's a variety of different measurements possible. But the, 25OH vitamin D is the one that's really gives you an assessment of vitamin D status in the body. 

Dr. Dacre Knight: And you know what? In, my experience, and, I, guess you too, do you check it on all of your patients?

Absolutely, yeah. Yeah. L- likewise. And- And I've had some kind of question what, you know-- Or maybe even some Medicare coverage, like even, you know, maybe not wanna cover it, right? is that also been your experience? 

Gregory Plotnikoff: So Medicare coverage differs around the country, and it's very political. It's not based on science, it's based on politics.

And there's lots of reasons why, insurers [00:15:00] may not cover a vitamin D test. So, for example, it's not covered for chronic pain. I... Now, it's covered for osteoporosis or kidney failure or, you know, hyperparathyroidism or, sarcoid or something. But, but you can purchase it from your local health plan. So if it's not covered locally, the retail price for vitamin D, if you go to Allina Health Plan or, others, is, well over two hundred and twenty-five dollars.

The wholesale cost is around twenty dollars, and so it's garbage to pay that much money. I think Quest will do it, directly from their direct cash pay, direct to patient type practice for about seventy dollars. 

Dr. Dacre Knight: So I've got another-- one more question, if I may, before I know Dr. Bluestein's gonna have something ready, raring to go.

But, you know, I was [00:16:00] thinking about a-as you were describing it earlier, about those who, again, different climates, Minnesota versus Pakistan or elsewhere in the world. And, thinking to myself, you know, I would wonder if Dr. Plotnikoff can tell us about, you know, sun exposure and how much sun exposure would be ideal.

and maybe before the London Tourism Board comes after us here , maybe then you can e-explain then what your management might be in different settings if they-- If you were in London, practicing in London, or if you are, you know, practicing in a northern climate, how would that-- how would you change that based on if you were, say, in, in Florida or, you know, somewhere else?

Gregory Plotnikoff: Well, Minnesota is forty-five degrees north, so we're exactly halfway to North Pole. London's about fifty-two degrees. Edinburgh and, is, even further north than, that. and but you think about forty-five degrees north, that's really the [00:17:00] Spanish-French border. and so it's kind of, for things.

Here's a key point. In Minnesota... Well, actually, the key point is what matters is, the angle of declination of the sun. And I guess I can't really illustrate that so much there, but the lower the sun is in the sky, the more-- the greater the distance light has to travel. And it w- in tr- in that travel, The small part of the spectrum, the ultraviolet B between 290 and 315 nanometers, has just the right amount of energy, or not, to actually go to a certain level in our skin and break open this double bond, which creates, goes from pre-vitamin D to a kind of another, kind of the vitamin D that's ready to be activated by the liver.

What counts [00:18:00] is how much energy does that light wave have? So if it's going through clouds, if it's going through smog, I don't know if you've ever- Not all 

Dr. Dacre Knight: light waves are equal then. 

Gregory Plotnikoff: Right. So, so picture this. Have you ever flown at an airport and where you've seen-- looked out the window and seen this like brown haze over the city?

Yeah, 

Dr. Dacre Knight: sure. 

Gregory Plotnikoff: Yeah. It's a vitamin D umbrella. and so it's been documented because the industrial pollution in Guangzhou, China, that the vitamin D producing rays in Hong Kong have gone down by twenty percent over the last couple decades. So, so a general guide is to recognize that, one, you can't make vitamin D through glass.

Impossible, no matter what time of day or, you know. You can't make it through clothing, you can't make it through sunscreen, and you can't make it through the [00:19:00] winter, at least in North America. Now, and here at halfway to North Pole, I say, tell people roughly you can make it between, Tax Day, April fifteenth, and Labor Day, early September, between the hours of ten and three if you're outside, with exposed skin, no sunblock, but safe sunning.

there's this like, no burning please. yeah, if you're pinking up, they say it's too much. But another general rule is if your shadow is shorter than you are tall, then you're-- it's-- then you have a good chance of making vitamin D that day. But for the people out jogging and walking before work early in the morning or doing it late afternoon, you can't really make vitamin D there.

It's good for other reasons, but, but, but you know, [00:20:00] January, high noon, you stark naked in the middle of the park and not make a drop of vitamin D. And so, and so how then do you get it? Well, supplementation is actually a great way to go. Mm-hmm. 

Dr. Dacre Knight: Well, that answers that. And, we might have stirred up some of our dermatology colleagues in Florida, but, but at least we, have dissolved the London Tourism Board now, so it is possible to live with good vitamin D levels in northern climates 

Gregory Plotnikoff: It, it is.

But I should just mention a, recent study just published, you know, a couple weeks ago, out of Birmingham, England, demonstrated a huge percentage of pregnant women with profoundly low levels. And, earlier in, Edinburgh, Scotland, 100% of the people in one primary care practice were severely vitamin D deficient, published in the British [00:21:00] Medical Journal.

and, and so yes. And so another key point is the darker your skin, there's more likelihood, that your, near ancestors were more equatorial than more North Polish. the darker your skin, the more sun you need to make the same amount of vitamin D. So if one-- So Minnesota has a lot of Somali refugees.

They can't make any vitamin D. And a recent study done at one clinic demonstrate that the average vitamin D level among Somali women in a, prenatal clinic was six. Now we wanna see above 30. And, and so yeah. So there's some real, concerns that, even though we are aware [00:22:00] of these issues, they're not being implemented by the health systems.

And so... And that's-- it's, a line item veto issue. It's, by some bureaucrat in the system not recognizing that there is a, that there's a huge racial disparity in this issue. 

Dr. Dacre Knight: Well, it's something it's im- important to know, right? It's important to make these observations. So, you know, we're, treating patients, all patients as best we can.

So thank you for that. That's excellent points. 

Dr. Linda Bluestein: A- and I have to say, as somebody sitting here with a headband on because I had major skin cancer surgery last week, you know, the whole sun thing is really tricky. I got a lot of sunburns growing up in Southern California, and I'm now paying the price.

I've had 10 basal cell skin cancers. I've had four Mohs surgeries, ins- including a redo Mohs surgery. So I'm really curious to know more about the balance of sun exposure and, are there any downsides to [00:23:00] supplementation versus, you know, getting it naturally? Because I now you know, it's a little late, the c- cow's out of the barn, but I'm super aggressive now with, you know, sunscreen and hats and all of that because I've, had enough of this nonsense with all of this skin cancer.

But, so, so is there a downside to getting it through supplementation? And then can you tell us more about what the goals are? And then my last part of this multi-part question is, also can you comment, Dr. Plotnikoff, on the genetic differences in, processing vitamin D? Because I understand that's a factor as well.

Gregory Plotnikoff: Well, yes, it's a multi-layered question. And before we get to that multi-layered question, just let me just point out, low vitamin D is definitely a risk factor for multiple cancers, and it's been suggested as a, significant risk factor for skin cancer as well. Now, also, since we're on the topic of nu- [00:24:00] nutrition and, skin cancer, New England Journal of Medicine had a very interesting randomized controlled trial a number of years ago around nicotinamide and basal cell.

And, and that low nicotinamide levels were definitely linked to, increased risks of basal cell, and supplementation actually reduced the frequency, in, a high-risk population. So we don't hear much about vitamins in general in healthcare settings because I think the three of us will agree that it is just that's not the mission.

I mean, nutrition may... You're gonna say, "Oh, Plotnikoff, you are so cynical," but okay, bear with me. Nutrition may be important for health, but it's not for medicine. So, so, so- 

Dr. Dacre Knight: Yeah. 

Gregory Plotnikoff: We expect 

Dr. Dacre Knight: people to get it a- as they go about their day, right? Yes. Yes. [00:25:00] It, just happens. 

Gregory Plotnikoff: Or it just happens. I, as, one dermatologist told one of my patients, I kid you not, he said, "Eat more broccoli."

What? There is no vitamin D in broccoli. That's good. Yeah. There's all kinds of reasons to eat more broccoli, but not- Yeah ... for vitamin D. No one's gonna get enough vitamin D in their food unless they're drinking two gallons of milk a day, and I don't recommend that for anyone. And so, so supplementation is a great way to go.

As we learn more and more that skin is an endocrine organ, that there are other reasons why, you know, why it's good to have sun on our skin, safe, and, but safe sunning, no burning. All kinds of things relate to mood and, multiple other effects we don't need to go into If one has the option of being outside, and many of us don't, but if you have the option [00:26:00] of being outside, that is, is always good and reasonable, but you don't really know how much you're, getting.

Here in Minnesota, we do know if you play hooky in the summer and go to the beach, you can get about 20,000 international units that day, as long as you don't burn. But f- but for most people with supplementation, a general rule of thumb is, and this is based on Minnesota experience, but it would apply to Los Angeles if you're indoors all day and, Houston and Tampa and definitely, you know, Maine and Alaska and the like.

But in general, a thousand inf- international units for every 35 to 40 pounds of weight. You say, "Well, wait a second. The RDA doesn't have anything to do with weight." And I would say, "Well, [00:27:00] how-- where did that RDA come from?" Well, essentially, here's the science behind it. One article published in 1940, an issue of JAMA, a multi-page, review on the topic of rickets.

And in that review article, there's a couple paragraphs. Why do these white kids in Boston not have rickets? Oh, they're taking cod liver oil. Oh, how much? A tablespoon. How much vitamin D in that? Four hundred international units. And for many decades, that was the standard. that's where the 400 international units came from.

It was repeated in a 1953 pediatrics article and really taken as gospel truth. And even when the ins- what's-- the Institute of Medicine did a review ar- review on vitamin D a number of years ago, they only raised it to 600, and it was based on some [00:28:00] really faulty reasoning, as if there's no difference between Black and white, young and old, thin and big, Anchorage and Tampa.

It, just makes no sense at all, and they did some hand-waving and some mathematics, but practically on the ground, it doesn't make a, it, it-- that does not translate to, be enough for anyone. I like data, and so here's some specific data. In a study I did of 6,800 women of childbearing age working in the Allina Healthcare System, so this is a subset of the 14,500 we studied, we asked the question, okay, what-- And we did the vitamin D level twice, two separate springs, And, and then we asked what, dosing people were taking.

And then we asked the [00:29:00] question, for BMI less than 30 and a BMI greater than 30, what dose was needed to guarantee that 97.5% of that subpopulation would achieve a bare minimum level of 20 nanograms per ML? The answer is, for women under, 30-- a BMI of 30, it was 2,500 international units per day, or four times the RDA.

And for women with BMIs greater than 30, it was 4,500 international units per day, or, you know, what's that? About eight times the RDA. we submitted that article to JAMA and it was rejected. They said, "Oh, this is 92% white, The population is 92% white. They, very few smokers. they all had health [00:30:00] insurance, they all had access, and they all had, you know, kind of some found-- foundation of, of, knowledge.

This is not generalizable." The article was rejected. it just left me so depressed. I, I, 

Dr. Linda Bluestein: That's understandable. I... And, I wanna just clarify something 'cause I, don't know if other people are confused since I'm a little bit-- I don't wanna say confused, but I just wanna clarify. So are you-- you're saying that if the BMI was less than 30, they needed 2,500 IUs in order to have a minimum level of at least 20, and if their BMI was greater than 30, they needed 4,500, because you also had said earlier that there was something about 1,000 IUs per 30 to 40 pounds of weight.

And I just wanna make sure, 'cause BMI versus actual body weight are two very different things. So I just want-- I don't want people to be confused with all the numbers, because these are important. These are very important things for them to know about. 

Gregory Plotnikoff: The general guide of 1,000 international units for every 25 to 30, or excuse me, 35 to [00:31:00] 40 pounds, is based on general clinical experience.

The, the, looking at the BMI less than 30 or greater than 30 was an epidemiologic study. And, and the, general guide is you look for, what will guarantee 97.5% of a population will be sufficient in a nutrient, and, that becomes the, the guideline. and bas- you're always gonna miss two and a half percent, apparently.

Dr. Linda Bluestein: And, before we go to the break, I, bet a lot of people are listening to this and they're fascinated. And I, I started checking vitamin D levels immediately. As soon as I started my clinic, I did recognize that this was a Low-hanging fruit that we definitely needed to, address. I'm so glad we're finally having this conversation

It only took me, what, six years to get here. Okay . Hope- hopefully no one's keeping track of that, but no, I've t- I've been talking about it, but not in this, depth. so before we go to the break though, I would love to know, [00:32:00] what is the goal we should be aiming for? 'Cause you've talked about, you know, greater than 20, greater than 30.

In a perfect world, if you could dial in a number for people, what would that number be? 

Gregory Plotnikoff: Okay. So this is, a very important question for which we need really solid data that does not yet exist, and it may be for different goals. In general, we wanna see everyone above 30. There's epidemiologic evidence to support levels, that ideal levels may be 40 to 60.

and, and this goes back to your-- the question I didn't answer about the genetic variability among us. there are, you know, vitamin D breakdown enzymes. There are issues with, body mass index as a fat-soluble vitamin. there are issues with vitamin D binding proteins. [00:33:00] there are issues with vitamin D receptors, through the body.

And so we're talking really kind of general guidelines. Specifics will be coming, you know, in the... You know, AI will probably, you know, kind of give us some guidance on that at some point. But it gets-- it, there are multiple factors or confounders, and things. So, but in general, we can say that, yes, above 30 for everyone, and in general, we can say, eh, it's likely 40 to 60, is good for a population.

It may be different for subpopulations, but we don't have data to guide that right now. 

Dr. Linda Bluestein: Okay. And is that nanograms per ML? What are- Yes ... what are the units? Yes. I just wanna make sure. Okay. Okay, 

Gregory Plotnikoff: great. Yes. Well, thank you for clarifying that because there's also nanomoles per liter, and the nanograms per ML, [00:34:00] is 2.5 times higher than the nanomoles per liter

or excuse me, the nanomoles per liter is 2.5 times higher than nanograms per ML. 

Dr. Linda Bluestein: Okay, excellent. So that, so those, units, my dad was a, an aeronautical engineer, is an air- aeronautical engineer. Kind of once, once you're doing it, you're always doing it. So, he, would, really get me on the units thing if he, if...

He's not gonna watch this episode, I don't think. But if he did . Okay, we're gonna take a quick break, and when we come back, we are gonna talk more about vitamin D and, you know, do you need to be concerned about toxicity? how does vitamin D interact with connective tissue and, so many other things. So we're gonna take a quick break, and we'll be right back

Thank you so much for listening to "Bendy Bodies." We really appreciate your support. It really helps the podcast when you like, subscribe, and comment on YouTube and follow, rate, and review on all audio platforms. This helps us reach so many more people and spread the information to everyone. Thank you so much [00:35:00] again, and enjoy the rest of the episode.

So we're back with Dr. Plotnikoff and Dr. Dacre Knight talking about so many things. I s- I wanna say all things vitamin D, but obviously in this, you know, duration of conversation, we can't get to all things vitamin D, and I don't wanna be misleading. before we move on to some specific, you know, hypermobility, connective tissue type things, I just wanna ask in terms of dancers and athletes, they experience higher rates of things like shin splints, stress reactions, stress fractures, et cetera.

can you tell us a little bit about how vitamin D and low levels could play a role in that, and also in tendon health or soft tissue resilience? What are some things that athletes and dancers should know? 

Gregory Plotnikoff: Well, thank you for asking. I'm a big dance fan, and so I get chances to meet with dance troupes as they come through Minnesota.

And recently it was the Joffrey, and before that it was, Hubbard Street and ABT and others. And I ask whenever I get the [00:36:00] chance, I go to the receptions for these artists, I always ask about vitamin D. And it was this kind of one-track mind, but I'm so concerned because these awesome artists, athletes, no one's talking with them about vitamin D.

And, in fact, there are even dance, you know, clinics around the country and I ask, "You go to... Do they measure your vitamin D?" "No." "Are you taking vitamin D?" "Well, I'm taking a multivitamin. I started a couple weeks ago." What? No, please. You know, vitamin D is critical for muscle function, it's critical for bone, it's critical for tendons, among a zillion other things.

and no one wants to be, you know, missing a performance or much less missing months of, practice, because of a vitamin D def- you know, deficiency-related concern. [00:37:00] and so, so I'm really hoping that the word gets out that at least measure your vitamin D if you're not taking vitamin D already every day at, decent level.

we know from the US Olympic team that if you're going for a gold medal, you need a normal vitamin D level. Or, we know from the NFL that the, you know, here are these multimillion-dollar a year athletes. The lower the vitamin D, the higher the risk of on-field injury and the slower the recovery Now, I'm a hockey fan of sorts.

I grew up, in Chicago. Chicago Blackhawks never won. And a number of years ago, they actually all got measured for vitamin D. Now, these are top athletes, again, performing at very high levels, but they're indoors all the time. Hockey rinks are indoors, and in the winter, if they're outdoors, they're not getting [00:38:00] any vitamin D from there, and much less they're all suited up.

And, they were all found to be low in vitamin D. They were all started on, vitamin D, and that year they won the Stanley Cup, first time in fifty years. and so low cost, low toxicity, you, you don't have anything holding you back or putting you at risk. Now, the U.S. military has reported that in re-- nineteen-year-old recruits, I think this was in South Carolina, it's the risk of stress fractures was profoundly higher, in people who are low in vitamin D.

In fact, nearly everyone with stress fracture had low vitamin D. So it's all types of people en-engaged in physical exertion. I, pulled an article out here, just published in May of '26, "Association of Vitamin D [00:39:00] Deficiency and Supplementation With Clinical Outcomes in Multitendon Chronic Tendinopathy: A Retrospective Clinical Trial."

Bottom line was vitamin D was critical for recovery from a tendinopathy. They had higher pain scores if their vitamin D was below twenty, longer disease duration by twofold, over eight months versus four months, and a higher prevalence of chronic tendinopathy of eighty percent versus twenty-four percent.

So my plea to all athletes, to all dancers, to, people engaged in, in strenuous activities, yes, yes, vitamin D might be really good for your pickleball. 

Dr. Dacre Knight: And I think maybe you just spilled the secret of how the U.S. men's hockey team won the gold medal this, this Winter Olympics. They, just, they got their vitamin D.

Right. Yeah. that's [00:40:00] great. Thank you, Greg. And, I do wanna ask about vitamin D toxicity, but o-one quick thing is, and I was thinking about it as we were going through the discussion about, Dr. Bluestein just sharing, you know, the, effects of what we know can happen if you get too much sun exposure.

But I was thinking again about my question for you about northern climates, m-management of patients in northern climates versus those in sunny climates. And, really, truth be told, as you pointed out, it, it-- we really have to be cognizant of it all climates because of how much time we spend indoors nowadays, right?

And there's And potential for so many people to spend, their whole, all waking hours in, inside, whether they live in Tampa, Florida, or, Los Angeles. So, so yeah, just, another, yeah, point of, clarification to, to, to my questions for you. But, yes, so we've been e- expounding upon all of the benefits of vitamin D and, you know, we're all gonna be ready gra- you know, reaching for the bottle a- as soon as we can.

But [00:41:00] yeah, let's, get it clear. Is it possible to get too much vitamin D? 

Gregory Plotnikoff: Oh, sure it's possible. there's, a woman, a wild story was a woman was working in a, a milk, bottling plant in the UK, and had decided she wanted to get rid of her husband, so she was taking vitamin D and kinda like putting it in his soup, and he got millions of international units and got sick.

She got arrested. But it took millions of units, and he, at best, he just got acutely ill. It-- And, more than, you know, it's kinda like, what? I've been, you know, I've been in medical practice 40 years now, and, at least since, kind of the '90s been working in vitamin D. I've yet to see anyone [00:42:00] with a real vitamin D, toxicity.

Now, there have been infants who accidentally were given a zillion units, and that is toxic. And we know we use vitamin D to kill rats. how, is it that, vitamin D got a reputation as, a rat-killing poison? Well, it's because you overdose the rats with vitamin D- and, and that is toxic, and it's toxic to infants.

but it's really hard. There, I've, you know, seen people with 10,000 international units a day, and I d- never recommend that much unless someone is profoundly deficient to begin with. But I've seen people with 10,000 international units a day who've been on self-dosing for years and come back with a level in like the 90s or, low 100s.

the known [00:43:00] toxicity from rat poison ideas is if you become hypercalcemic. And so here's the, more likely thing is if you're taking in a lot of calcium, and let's say someone's been told to take, you know, 1,200, you know, milligrams of calcium a day, and you got a high dose of vitamin D, the most likely complication that could come from that would be like kidney stones.

No one wants a kidney stone. but, you know, part of the thing is this recommendation of like 1,200 or 1,500 milligrams a day of calcium, was based on vitamin D deficient women. And Robert Haney at Creighton did a study where he, looked at calcium absorption with people with a, a vitamin D level of 20 versus those same [00:44:00] people with a, of absorption at vitamin D level of 30.

And it showed that going from 20 to 30 improved calcium absorption by 65%. Oh, this 1,200 international unit or 1,200 milligram recommendation for calcium, does it apply to everyone? Well, if it's based on vitamin D deficient women, I'm, not so sure, that's the-- sorry, no, there is a mandatory 500 milligram a day loss of calcium, it's believed, and so we need at least that.

But high-dose vitamin D and high-dose, calcium, not a good combination. Yeah. 

Dr. Dacre Knight: I've seen that in my practice. Yeah, definitely. 

Gregory Plotnikoff: Yeah. So the big point is that we want everyone to remember is dose determines poison. We don't know, what the blood level is without measurement. So this is why a measurement [00:45:00] is so important.

So if someone says, "Oh, yes, we live in a more is better culture," and, you know, and, you know, Plotnikoff said, you know, "3,000 a day, but I'm gonna do 20,000 a day," well, that's not a good idea, with-- And so working with an informed health professional or getting measurements, really are important guidance.

And we have to remember that vitamin D also works very closely with magnesium. And it's Linda, getting back to your question about, you know, kind-- the genetics and things. We know magnesium is a critical cofactor and made the transformations of vitamin D, both its production and well, its breakdown.

and then they-- magnesium and vitamin D also work together at the muscular level, at the cellular level, at the, sarcomere level. It's very, important, [00:46:00] for function. And vitamin K is also really important as part of this as well. So It's really more of a kind of a, complex, of things, that, really work, together 

Dr. Linda Bluestein: So as soon as you said that, I'm picturing the emails.

Gregory Plotnikoff: Okay. 

Dr. Linda Bluestein: what, w- what exactly which vitamin K, what dose, magnesium. Of course, we've talked about magnesium before a little bit, but, if you could share some specifics, of course, knowing that this is not medical advice. This is, you know, general information. Everyone needs to consult with their own team, but I know people are gonna be asking these questions.

I, I'm always like, you know, listening to for this, oh boy, this is gonna be a, something that p- a lot of people are gonna ask about. 

Gregory Plotnikoff: Okay. Well, good. Well, thanks for pointing that out. So I never promote any commercial products or purposes, so I won't use any brand names. However, in general, I also focus on food first.

And I just mentioned there really isn't any vitamin D in food. You know, it's just, you [00:47:00] cannot, it's just not enough even if no matter what any kind of site says, you just-- it is just not nearly enough there. magnesium sources, when you think about anything that's green and leafy, and inside that chlorophyll is a magnesium.

magnesium can be found in just a non-processed and kind of whole foods diet will have a fair amount of magnesium in it. Vitamin K is also think about green leafy vegetables, and I like vitamin K2. There's, found K1 and K2, and some people have difficulty converting K1 to K2, and so I, lived for many years, I lived in Japan.

Was a professor of medicine in Tokyo, and, I happen to like natto for breakfast. And it's stewie-- it's gooey, it's, messy. You know, you can't eat it without having a spider web of goo on your face. But, [00:48:00] but that's a great source of vitamin K2, among other things. And, but what do I do? I do, a magnesium glycinate.

I do a vitamin D and K2 combo, and that kind of covers everything right there in two capsules. And I do the best I can with diet. and, but you know, it's 15 minutes a day is just 1% of the day, and there are many days where I do not have 15 minutes outside. And, yeah, shame on me. it's kinda, it's not a good thing.

But do people say, "Oh, he's finished for my own time outside." Well, all right. Every 15 minutes is 1% of your day. Did you make it to 5% of your day today? 

Dr. Dacre Knight: That could take a lot. So, so what I'm hearing you say, Dr. Plotnikoff, is that, vitamin D is safe. I mean, in theory, you could have too much, but what happens really w- when we get concerned about is it, is, as I mentioned, I see [00:49:00] in my clinical practice too, is The concern about hypercalcemia because what you've now taught us is that there's almost like an ac- acceleration effect of calcium absorption, right?

As the vitamin D is, coming in. 

Gregory Plotnikoff: Yeah. So the, kidney stones are a big issue. And, there's certain medical conditions where you have to be really careful, sarcoid being one. hyperparathyroidism is a really interesting one. I swear I've seen people who have had their parathyroid surgery and-- but it turned out to be, actually it looked like it was vitamin D deficiency that was causing the elevation that led to the surgery.

So that's why I really like the idea about, you know, partnering with an informed health professional. And, this is my soundbite of the day. Self-diagnosis and self-treatment sometimes results in self-malpractice. That's 

Dr. Dacre Knight: [00:50:00] a good one. I'll, like that. Yeah. And, to, carry that further too, so yes, e-emphasizing your shared partnership with your, health professional, but this is fairly easily managed.

You're, monitoring labs, you're getting a supplement, and you're getting on the right path. And it is, low-hanging fruit. So, you know, by all means-- and, if it's, you know, happens to be cash pay, it's s- seventy dollars for a lab test. So, so yes, to, go then a little bit forward on that, let's say we're doing those things and, you've mentioned some of the symptoms that can happen with low vitamin D.

What's your thought process then if you've got someone well-managed on vitamin D, but they may still be having some of those symptoms? 

Gregory Plotnikoff: Okay. Well, that's, the thing is, I like what one of my, mentors said. She said, "Greg, if you make the right diagnosis [00:51:00] for someone, great. But if you haven't thought about five other biologically plausible explanations for their experience, you're really not a good doctor for them."

And so I'm always thinking, what else? What else? What else? Part of the messaging here is that what else can be vitamin D deficiency that people aren't considering. but there are so many other things. That's why working with informed health professional is so important is as a, thought partner.

You know, you bring your ideas, bring your research, and, I think thought partnering is, a very empowering way, of doing things. I particularly dislike the term provider whereas it really makes it sound like, oh, I'm handing all my, all my, health over to someone else who will do the work for me.

And I tell people, you know, f- [00:52:00] fellow health professionals, "Don't be a tow truck." Now, here in Minnesota, where we got snowy roads, people slide off the road all the time. and you've got two options. One is you can get out the cat litter to put... and the snow shovel and dig, and, get some traction, and maybe call some friends to help push you out, but you can get out under your own power.

Or you can call AAA, and just a tow truck comes get, gets you. And I think every time I hear the word provider, I'm thinking people are, thinking of their health professional as a tow truck, someone who's gonna do all the heavy lifting for them. So 

Dr. Dacre Knight: handing it over to them, yeah. 

Gregory Plotnikoff: Yeah. It's disempowering.

And so everything we're talking about, everything your, podcast is about empowering people. Knowledge is power, and, everything here is, you know, kind of, you know, supporting people to get, you know, [00:53:00] optimize their health. And yes, there's can be a gazillion reasons why people can have musculoskeletal pain and weakness, fatigue, and, tendinopathies and, more.

And we need to consider all the biologically plausible dimensions, vitamin D being one of many. But it's something that, unfortunately, it's easily overlooked because of this term vitamin, and vitamin's just, it sounds too woo 

Dr. Linda Bluestein: Yeah. that's a perfect lead into what I was gonna ask next, which is, you know, if somebody's...

Nowadays, you know, we have all these direct-to-consumer lab options, as you guys were discussing earlier. Like, somebody could go and get their own vitamin D level checked without an order. you know, back when I went through medical school and residency, this, these of course were not options, but they are now.

Not that we want people to feel like it's all their responsibility, because it has to be a balance, right? It has to be a balance between those things. and some- not everyone can afford even the $70 for a vitamin D test, [00:54:00] so I love that we're giving some ideas for people. Again, they need to consult with their own team, but just some general, you know, guidelines that are in the literature in case they're not able to afford the vitamin D test.

But let's say somebody can afford to pay for a vitamin D test, and maybe they wanna check some other labs as well. There are things that you, Dr. Plotnikoff, kind of consider to be, you know, kind of standard for your patients that have chronic pain, inflammation. You know, I know now I'm getting a little more greedy, mast cell, POTS, EDS.

what are, the general labs that you would see as being foundational in addition to vitamin D? 

Gregory Plotnikoff: Oh, the Plotnikoff top five. Okay. So first- We're rolling with soundbites today, right? This is great. Love it. I can only think in soundbites. But, actually, you know, so vitamin D, yes.

I like, essential fatty acid [00:55:00] profiles, omega-3s and omega-6s. And, I see people who have profound omega-3 deficiencies. I constantly see people with profound omega-3 excesses. And, same thing with omega-6s, either too much or too little. And you can really only assess that through a blood test, so that's kind of a big one.

I like to see reactive protein for general inflammatory, guide, for things. when it comes to musculoskeletal and joints, you know, the ANA, autoimmune screen, you know, kinda stands out. So those are kind of four, easy, ones to do. The fifth one is, is homocysteine. And homocysteine's a very inexpensive blood test that, is a great indirect marker of how methylation is functioning.[00:56:00] 

And methylation is a key pathway in our body relevant to mood, memory, energy, sleep, bone health, and a zillion other things. There are over 200 methylation-dependent enzymes in our body, and high levels of homocysteine are not good. and they're definitely linked to, all kinds of neurologic issues, and more.

now this could maybe be a whole 'nother podcast, but let me just share with you that despite the fact that the evidence, that the circumstantial evidence is very high about, about homocysteine being a major risk factor for neurologic issues, and, blood clotting and, mood issues and so much more, very, few people measure it.

And at [00:57:00] two meetings of the, meetings of the grand poobahs, the geeky internists, the American College of Physicians, two times, I've been at the conference and asked about homocysteine, and the first time was, "Huh, not aware of A data. Next question." and that was a world-famous professor of neurology, and you're in a room of 900 geeky internists, the average age in their 50s, so they have both a personal and professional interest in this topic.

And, I said, "Gosh, thank you for this presentation. you didn't have enough time to talk about nutrition metabolism." So thinking I'd throw him a softball, I said, "Could you please address homocysteine? You know, it's low-cost measurement. It's easily addressed by, you know, over-the-counter nutritional issues-" It's so strongly linked to dementia and so many other things.

Could you please [00:58:00] comment on it?" And the answer was, "Huh, not aware of any data. Next question." So because there was a long line behind me, I wasn't gonna be rude, but on that day in 2019, there were 987 articles tying homo- elevated homocysteine levels with dementia, and that was in National Library of Medicine.

Today, it's over 1,200, including international consensus statements saying, "Well, there's nothing else we can do. At least do that." So you say, "Plotnikoff, do you have a bit of an agenda?" And so it's yes, low cost, low toxicity interventions that, that can make a big difference. So the vitamin D, the fish oil, the CRP, these are kind of, they make a...

And by fish oil I mean by the omega-3, omega-6, profile. y- you know, autoimmune screen, if that makes sense, and homocysteine. these [00:59:00] are, th- these, If I was doing a f- a foundation pattern, a panel, this would be, key elements in the center of everything because in, in my 40 years experience, I can say these are ones that have, led to the kind of biggest insights and breakthroughs for the least amount of effort and cost.

Plotnikoff five, I love it. That's 

Dr. Dacre Knight: it. But i- and, I keep thinking... I'm, really, I'm just gonna have to go back and listen to this recording again myself because I keep thinking of questions as you're talking and trying to retain the information, and, I get so excited 'cause you've got this encyclopedic knowledge of, these things.

And, o- one thing that has perplexed me and, I just wanna hear your input on it. So well, actually a couple things, but first, do you prefer daily, vitamin D supplementation or weekly? I know that there's some differences there. How, do you approach that, just to start? 

Gregory Plotnikoff: Well, thank [01:00:00] you. That's a, big point.

So a lot of people, they say, "Oh, your vitamin D is low. Here, let me prescribe, ergocalciferol or yeah, ergocalciferol 50,000 international units once a week." so back, back in the, '90s when I was first exploring this, I was one who came out and said, "Treat with ergocalciferol because, it, has such a short half-life."

So ergocalciferol, it comes from ergosterol and, mushroom membrane cell walls exposed to ultraviolet B. They'll turn it ergocalciferol or vitamin D2. In our body, we have vitamin D3. But it's close enough and it does the job, and I'd recommended [01:01:00] that because back in the, you know, back in the '90s when, you know, 400 international units going to 800 seemed scary, this is what recommended.

The once a week is great, but two weeks later it's gone. And so, so it was-- I felt safe recommending it because if, we got in trouble, it would be gone so quickly, and, but no one ever got in trouble. People tend to underdose that. Some people really require 50,000 twice a week and plus 5,000 a day on, of D3 on top of that.

But D3 is what you buy when you go to the grocery store, and it says vitamin D or vitamin D3. They're one and the same. That's cholecalciferol, and that's, that's bioidentical to what's going on in our skin. and, And you just 

Dr. Dacre Knight: answered my second question, so thank you. That's the- Yeah. Okay ... that's it.

What do you, see in the store? Yeah. Okay. 

Gregory Plotnikoff: Got it. Yeah. So vitamin D3 has a longer half-life and, but I tell people, "If you go out for [01:02:00] wonderful, you know, okay, Labor Day picnic and get lots of sun, here in Minnesota, your vitamin D from that picnic is gone by Halloween." So I do like daily, just makes it, you know, daily things like brushing your teeth, it just gets done.

once a week and just kind like, we're all too busy to remember, what, day of the week is it? 

Dr. Linda Bluestein: That makes sense. as you know, we like to wrap up every episode with a hypermobility hack. can you-- Do you have a hack for us? You've already given us some hacks, but do you have an additional hack for us?

And then can you tell us where we can learn more about you, where people can find you online or in clinic? 

Gregory Plotnikoff: Okay. Well, I practice, at Minnesota Personalized Medicine, here in Minneapolis, Minnesota. and our practice here is focused on complex chronic mysterious illness. So it's so if I come across as a little geeky, that's really where, [01:03:00] this is, my contribution to the planet.

I... When people are facing really complexity and they've done the, made the rounds and, and they say, "Well, it's not the right kidney. Go see the left kidney doctor," and it's kind of like this is where I add value. And a team here, Dr. April Lind and Dr. Tara Doyle, we enjoy, being help- meaningfully helpful for people with, challenges.

And am I in the 21st century yet? Kinda. There's LinkedIn, there's, and there's kind-- I think our clinic has an Instagram and a Facebook account and things like that where we, post things. Certainly I, post on Link- LinkedIn, every so often, particularly during the horrors Recently, in Minneapolis, that was a important site.

but a hack. Well, I think, because vitamin D [01:04:00] is free from the sun, I like this idea of, if you're outside and your shadow is shorter than you are tall, then you can make vitamin D. And, and so, you know, it's, free, safe sunning, no burning. But a lot of days we don't have a shadow, and many days, or many times of the day our shadow is much, you know, longer than we are tall.

And we just can't make vitamin D then, so. 

Dr. Linda Bluestein: Very good. Well, thank you so much for sharing your knowledge with us. You obviously have deep knowledge on so many different topics. I feel like we could talk about, you know, homocysteine as a whole separate episode and, so many of these other things, the fatty acid profiles and, things like that.

So we really appreciate you taking the time to share this information with us today about such an important topic that I think so many [01:05:00] people will benefit from. So thank you. 

Gregory Plotnikoff: Thank you both. I, really appreciate this, and, I hope that this, podcast, this particular one, I know all of them are, really good, but I hope this one is meaningful for people.

And so if it is meaningful, please, write, Dr. Bluestein, Dr. Knight, and let them know, and comment. And, and if you can also, if you generate a, question that, from this, I am most open to questions 

Dr. Linda Bluestein: I'm super excited to tell you about the Bendy Bodies Boutique. I am so proud of our fierce styles and flexible designs.

These are created by hypermobile artists for hypermobile shoppers. There are so many fun items from clothing, accessories, home goods, and my favorite are the bags. I especially love the weekender tote with one of the EDS Tough designs. Whether you're shopping for yourself or someone you love, there's so many options to choose from.

A portion of the proceeds goes to support EDS [01:06:00] nonprofit organizations. For more information, please visit bendybodiesboutique.com. Thank you so much for listening to this week's episode of the Bendy Bodies Podcast. If you'd like to go deeper, I share additional education, clinical insights, and resources in my newsletter, the Bendy Bulletin, which you can find on Substack at hypermobilitymd.substack.com.

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