Low Vitamin D Levels, and Low Blood Vitamin D.

Low Vitamin D levels are very common in patients with hyperparathyroidism. Most patients with parathyroid disease (and high calcium) will have low Vitamin D lev els in their blood. Low Vitamin D is quite common, but many endocrinologists don 't understand the connection between low Vitamin D and parathyroid tumors... and will confuse the issue (and the patient with parathyroid disease) by saying the patient with low Vitamin D levels has "Secondary" hyperparathyroidism... This i s a myth. We will bust the Low Vitamin D myth on this page.

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LOW VITAMIN D is discussed on this page of parathyroid.com. This is an advanced parathyroid page, and if you have recently been told that you have hyperparathyr oidism (parathyroid disease) and/or high calcium in your blood, then you should read our other parathyroid pages first. We will give a short synopsis of Vitamin D in the blood, and low vitamin D levels... with some facts and take away point s. Then, this page will get more complex. If your endocrinologist tells you tha t your calcium is high because your Vitamin D levels are low... and wants to giv e you Vitamin D to make your calcium go down... then you should print this page and take it to them. This is wrong. As shown below, low vitamin D levels can nev er make calcium levels go into the high range. The bottom of this page is comple x and written for doctors and advanced patients. The top of this page on Vitamin D is for most patients... Here we go.

Overview of Vitamin D Vitamin D is essential to our bodies. We can't make it, so we have to get it in our diet, or get outside and have the sun make it for us (yep, sun light on our skin causes our skin to make Vitamin D). Vitamin D does one thing in our bodies. Only one thing... it helps our intestine to absorb calcium from the foods we eat. Thus, Vitamin D increases the amount o f calcium in our bodies. If our Vitamin D levels are low, then our intestines ha ve a hard time absorbing calcium. This is why milk is fortified with Vitamin D. Did you ever notice that the milk you buy has "Vitamin D Fortified" written on i t. We want our kids to drink milk so they get lots of calcium to build their bon es strong... but without the Vitamin D, most of the calcium in the milk won't ge t absorbed. Our intestines MUST have at least a little Vitamin D to absorb calci um. For you older people out there, did you notice that most of the calcium supp lements (Citracal, Oscal, Caltrate, etc, etc) will have Vitamin D added to the c alcium pills? This is because our intestines need the Vitamin D molecule to abs orb the calcium molecule through the intestinal wall and transport it into our b lood. AGAIN.... Vitamin D does only ONE thing in the human... it helps our inte stine to absorb calcium. Thus, increasing a person's Vitamin D levels will increase the amount of calcium they absorb from their diet. If a person takes more Vitamin D, then the intesti nes will become more efficient at absorbing the calcium molecules in our diet, a nd these calcium molecules will be absorbed... your calcium will go UP.

Vitamin D and It's Relationship to Hyperparathyroidism Hyperparathyroidism is associated with high calcium in the blood. The cause is a parathyroid tumor. This is discussed throughout this website, so we will not go into it here. Basically, a tumor grows from one of your parathyroid glands... t his tumor produces parathyroid hormone which takes calcium out of your bones and puts it into your blood. You get osteoporosis and feel bad because of the high calcium in the blood. The body doesn't want the calcium to be high... So, it will try to get rid of th e calcium in the urine... which is why many patients (about 1/3) will have high calcium in the urine (they can get kidney stones from this).

The body also wants to shut down calcium absorption from your intestines. It doe s this by limiting the amount of Vitamin D in your body. Thus, if your body dete rmines that your calcium is too high... it can decrease the amount of calcium th at is absorbed from your intestines by decreasing the amount of Vitamin D availa ble. If your Vitamin D levels are decreased, you can't absorb so much calcium fr om your diet. This is a protective measure.

Vitamin D in Patients with PRIMARY Hyperparathyroidism We began measuring Vitamin D levels in patients with hyperparathyroidism in the mid-1990's. For the past several years, we have measured it in most patients, an d beginning in 2006 we began measuring Vitamin D in every patient with PRIMARY h yperparathyroidism. Here is what we found in our recently published article on 1 587 patients with primary hyperparathyroidism: 67% of all patients with primary hyperparathyroidism will have LOW Vitamin D-25 Levels! This is 1039 patients out of 1587 in our study. 594 patients (38%) had levels below 20 ng/ml with an average Vitamin D level of 14.6. 33% of all patients with primary hyperparathyroidism will have NORMAL Vitamin D25 Levels (above 30). Their average Vitamin D level was 35.3 ng/ml. 0 % of all patients with primary hyperparathyroidism will have HIGH Vitamin D-25 Levels (we've only seen it a dozen or so times when examining Vitamin-D levels in over 8000 patients with parathyroid tumors). As the calcium level increases, the level of Vitamin D-25 decreases. The followi ng graph shows this nicely. When we look at 1587 patients with a parathyroid tum or (we know it because we removed the tumor and gave the patient a picture of it ), we see that those with higher calcium levels tend to have lower Vitamin D lev els. As you will read below, this is because the body is trying to protect itsel f from the high calcium, and it is converting one form of Vitamin D (Vit-D-25) i nto another form (Vit-D-1-25). This serves to decrease the amount of calcium abs orbed from our diet, to keep the calcium from getting even higher. Read that aga in... the body is protecting itself from the high calcium. It does this by decre asing the amount of Vitamin D in our body so we don't absorb as much calcium in our diet. As you can see from the graph below, the higher a patient's calcium go es, the lower the Vitamin D goes.

Figure 1: Vitamin D-25 levels in 1587 patients with primary hyperparathyroidism due to a parathyroid tumor. This graph shows the average Vit-D-25 level for all patients. The line is an average, so there are about half of the patients who ha ve levels above the line, and about half of them have levels below the line. As you can see, the line goes down as the calcium levels increase. Said more scient ifically, Vitamin-D25 levels decreased linearly as calcium levels increased such that 71% of those with calcium levels above 12 mg/dl had Vitamin-D25 less than 20 (p<0.001, R=0.91). Most patients with a parathyroid tumor will have low Vitamin D-25 levels. Those patients with more severe primary hyperparathyroidism (those with larger tumors and those who have had the tumor a longer time) will have higher blood calcium l evels, which are associated with lower Vitamin D-25 levels. The lower your Vitam in D-25, the longer you have had hyperparathyroidism and a parathyroid tumor in your neck.

We have graphed this information using a different graph so you can see it clea rly. This shows that nearly 40% of all patients with PRIMARY hyperparathyroidism have Vitamin D-25 levels that are below 20 ng/ml. 60% have vitamin D levels ab ove 20, but that includes 29% who have levels between 20 and 30, which is consid ered "deficient". Nobody with a parathyroid tumor has high Vitamin D-25 levels. Thus, their body is trying to protect them from the high calcium, decreasing the amount of Vitamin D levels so they don't absorb so much calcium. Well....... what is happening in these patients? What is the difference? Each o f these patients had a high calcium levels in their blood and high (or inappropr iately normal) PTH levels. Thus, each of them had primary hyperparathyroidism. W ell, every one of these patients was operated on by us, and we found (as expecte d) that they all have the exact same parathyroid tumor! (sorry, we are getting c omplex now... if we lose you, then go to the basic pages and come back here late r). That is, 98% of those with LOW vitamin D levels have a parathyroid adenoma a nd 2% have hyperplasia. 98% of those with NORMAL Vit D-25 levels have a parathyr oid adenoma and 2% have hyperplasia. Thus, there is no difference in these peopl e's necks.......they all have the same parathyroid tumors causing their hyperpar athyroidism... The Vitamin D levels have NOTHING to do with their disease. It is the parathyroid tumor that is causing the body to decrease the amount of Vitami n D-25. Not visa versa. This graph shows that 98% of people with primary hyperparathyroidism have a para thyroid adenoma (tumor) and 2% have hyperplasia... REGARDLESS of what their Vita min D level is. Thus, if your calcium is high, you have a parathyroid tumor and it doesn't matter what your Vitamin D level is. The vitamin D is not causing the parathyroid problem... The low vitamin D is GOOD... it is protecting you from e ven higher calcium levels. THEREFORE: IF YOU HAVE HIGH CALCIUM, YOU HAVE A PARATHYROID TUMOR IN YOUR NECK AND YOU NEED AN OPERATION TO REMOVE THE TUMOR. Vitamin D levels have nothing to do with it! The low vitamin-D levels is the body's way of preventing the intesti nes from absorbing more calcium! The body is protecting itself! DO NOT AVOID SU RGERY BECAUSE YOUR DOCTOR SAYS YOUR VITAMIN D LEVEL IS LOW... AND THE LOW VIT-D IS THE CAUSE OF YOUR PROBLEMS. THIS IS WRONG! This is a myth, and this myth is busted. The low Vitamin D did NOT cause the high PTH and high calcium... in trut h, the parathyroid tumor is making PTH which is taking calcium out of the bones and putting it into the blood. Furthermore, it is very typical for patients with parathyroid tumors to have calcium levels that go up and down... high sometimes and back to normal some times..... this is typical for patients with parathyroi d tumors. The tumor doesn't regulate the calcium well, and the levels go up and down. Why are we discussing Vitamin D and hyperparathyroidism? Because this has becom e a huge problem since 2007. Now that Vitamin D is easy to measure, many doctors (endocrinologists) will measure Vitamin D levels on all patients with high calc ium in the blood. They will also measure the PTH levels... they are trying to pr ove (correctly) that the high calcium in the body is due to a parathyroid tumor. Here is where they go wrong... and this is getting very complex.... If the Vit amin D level is low, then they think this is the MAIN PROBLEM. They think that t he low vitamin D levels cause too little calcium to be absorbed in the intestine s. They think that this low amount of calcium is sensed by normal parathyroid gl ands which causes the normal parathyroid glands to appropriately increase their production... causing a high PTH level. They further believe that this high PTH level will take calcium out of the bones and increase the calcium in the blood. Thus, they think the PTH levels are high because of the low vitamin D levels... thus they think the high PTH levels are high SECONDARY to the low vitamin D leve ls... thus they will tell you that you have SECONDARY hyperparathyroidism. THIS

IS A MYTH. THIS IS NOT CORRECT. Measuring vitamin D levels has nothing to do wit h making the diagnosis of hyperparathyroidism. Low Vit D levels will NEVER cause high calcium levels. It is not possible. Update: On July 19, 2007 the New England Journal of Medicine (NEJM) published a review on Vitamin D and these authors report the same results that we do here... that high levels of PTH will decrease Vitamin D-25 in many patient's blood. If your doctors continue to give you Vitamin D when your calcium and/or PTH are hig h, then you ask them (kindly!) to read this web page and this NEJM article: Holi ck M. Vitamin D Deficiency. N Engl J Med 2007;357:266-81. Having low vitamin D i s CAUSED by hyperparathyroidism, not the other way around! Getting complex even further... If you are still with us... If the low vitamin D was the starting point... if the low Vitamin D was the main problem... and thi s caused the parathyroid glands to increase their parathyroid hormone production ... then I would be an idiot to operate on these people... and if I did, I would find them to all have normal parathyroid glands... they wouldn't have 3 normal parathyroid glands and one parathyroid tumor. If the low Vitamin D caused the pa rathyroid glands to get big... they would all get big... but that is NOT what ha ppens! Patients with low Vitamin D levels have parathyroid tumors just like peop le with normal vitamin D levels. Remember, parathyroid adenomas are tumors. The entire tumor mass is made of cells from one parent cell that went crazy and repr oduced itself millions of times. Parathyroid adenomas are TUMORS... (did you see our page showing 80 typical photos of these tumors?). Low Vitamin D does not ca use TUMORS to grow. It is the other way around. To defend the endocrinologists (who mean well, but don't see enough patients wit h hyperparathyroidism to be "expert" at it... we see 3,500++ patients per year w ith this problem), it is possible to have LOW vitamin D levels to cause your PTH to go up a very little bit. BUT... this will NEVER increase the calcium in the blood, and the PTH will only go up slightly. Sometimes your endocrinologist will try to give you Vitamin D as a trial... to see if your parathyroid problem is d ue to low Vitamin D. The theory is that giving you Vitamin D will cure the caus e of the high PTH... and all your labs will go back to normal... They call this secondary hyperparathyroidism and they will give you a prescription for high dos es of Vitamin D. HOWEVER, this can be dangerous... if your calcium is above 11. 5, the additional Vitamin D can make your calcium go above 12 and we have even s een 4 patients have a stroke because of this, and another 38 patients need to be admitted to the hospital because their calcium was so high (updated 9/1/10). We have even seen an endocrinologist get sued for malpractice because he gave a pa tient with primary hyperparathyroidism high doses of Vitamin D which caused the patients calcium to go high and cause the patient to have a stroke! This is not a smart move. If your calcium is high, you should NOT take Vitamin D in large d oses. If you do, you will find that it almost always makes your symptoms of hype rparathyroidism worse. Is it going to cause you to have a stroke? nope.... but i t will make you feel bad and it will waste your time and money. If your calcium is high, you have a parathyroid tumor (PRIMARY hyperparathyroidism) regardless o f what your Vitamin D level is.

Remember above when we were discussing Low vitamin D... saying that decreasing t he Vitamin D in your body is the body's way to protect itself from the high calc ium? If this is true, then we should see the low Vitamin D levels in patients w ith hyperparathyroidism return to NORMAL once the parathyroid tumor is removed. Well, in January 2007 we began a trial to test this theory scientifically (we h ad observed it many times, but we decided to test it scientifically so we can pu blish it in a major medical journal... we publish on parathyroid topics about ev ery other month). Guess what!!!??? 95.6% of all patients with LOW vitamin D lev els had NORMAL vitamin D levels 1 month after their parathyroid tumor was remove

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Thus, proving yet another way, the body doesn't like having high calcium wh is due to the parathyroid tumor. The body turns off Vit D so we don't absorb much calcium. When the parathyroid tumor is removed, the body turns the Vita D back on and the low vitamin D levels increase back to normal.

The bottom line again: If your calcium is high, you almost certainly have a par athyroid tumor. If your calcium is high and your Vitamin D is low, you STILL hav e a parathyroid tumor. If your calcium is high and your Vitamin D is normal, you STILL have a parathyroid tumor. When you get your parathyroid tumor removed, y our Vitamin D level will almost always correct itself within 1 month! If your endocrinologist says "you have secondary hyperparathyroidism because you r Vitamin D level is low", then you MUST print this page and take it to them! Th is is not correct. You have PRIMARY hyperparathyroidism... and 67% of people wit h primary hyperparathyroidism have a low Vitamin D level (below 25 ng/ml)... it is expected. Get the tumor removed and get on with your life. Secondary hyperpar athyroidism due to low vitamin D is never associated with a high calcium level i n your blood. NEVER. If they put you on Vitamin D and then measure your calcium a month later... and your calcium gets better.... then they are fooling you and themselves... it will be bad again one month later, and you will feel bad. Trust me! This will make you feel bad. Get the tumor removed! UPDATE. In June 2008 Dr Norman gave a lecture to the Endocrine Society's Annual Meeting in San Francisco, CA on Vitamin D in parathyroid disease. Here is an abstract of this talk; the journal article will be published later in 2008. Print this and take it to your doctor who put you on Vitamin-D. Most endocrinologists know this already, but many do not: Vitamin D -25 is suppressed and Vitamin D-1-25 is increased in patients with pri mary hyperparathyroidism in linear fashion as calcium levels increase, returning to normal within weeks of tumor removal. A protective mechanism is in play. Overview: Vitamin D-25 is converted to Vitamin D-1-25 in patients with primary HPT in a linear fashion as calcium levels increase. Thus the vast majority of pa tients with primary HPT will have low Vit D-25 that normalizes by itself in most patients within several months. Objective: Vitamin D-25 is often measured in patients with apparent primary HPT to rule out a possible secondary cause. This study was undertaken to examine if a relationship exists between Vit-D levels and parathyroid pathology in patient s with elevated calcium levels. Methods: A prospective, single institution study measured preoperative Vitamin D (25OH and 1-25OH) in 1,587 patients undergoing surgery for sporadic primary hy perparathyroidism (PHPT) over a 1-year period. All patients underwent curative parathyroidectomy with pathology noted. Patients were put on nominal doses of Vi t-D postop contained within supplemental calcium tablets (Citracal+D; 250 IU cho lecalciferol daily) for two months; none took additional Vit-D. Blood levels wer e measured at 1 and 2 months post-op. Results: All patients had primary HPT with high serum calcium and PTH preop tha t normalized at all postop measures indicating cure. The average preop Vit-D25 w as 25.8+10 ng/ml (range 4-65). 1039 patients (67%) had Vit-D25 levels below 30 n g/ml preop, while 594 patients (38%) had levels below 20 ng/ml preop (mean 14.6, range 4-19), No patient had high Vit-D25 preop. Vit-D25 levels decreased linear ly as calcium levels increased such that 71% of those with levels above 12 mg/dl had Vit-D25 <20 (p<0.01, R=0.91).The levels of Vit-D1-25 were low in 0%, normal in 58.5%, and high in 41.5% (mean 56.2 + 14)(p<0.01). The findings at surgery

were identical (p=0.98) for those with low vs. normal Vit-D25 (single adenoma=92 %, double adenoma=6%, 4-gland hyperplasia=3%). 82% of patients with low preop Vi t-D25 had increased levels at 1 month postop (mean 41.4+12, range 17-63, p<0.005 ), increasing to 91% at 2 months. All patients with normal Vit-D25 preop remaine d normal postop. 68% showed decreased Vit-D1-25 into the normal range (p<0.001) within 1 month of surgery. Conclusion: Vit-D25 levels decrease in a linear fashion as calcium levels rise in patients with primary HPT. Overall, 38% will have Vit-D25 levels less than 20 ng/ml, increasing to 71% of those with calcium levels above 12mg/dl. Vit-D1-25 shows the opposite pattern suggesting a protective mechanism. The pathology foun d at surgery is identical in PHPT patients with low versus normal Vit-D25 indica ting no causal relationship. Low Vit-D25 should not be interpreted as signaling secondary HPT in patients with elevated calcium levels. The vast majority of pat ients will normalize their low Vit-D25 and high Vit-D1-25 levels within 2 months of tumor removal.