New research indicates
that Vitamin D may protect against COVID-19,
especially in Black people. Today, on At the
Forefront Live, we'll talk with investigators
about that research study, hear more about the importance
of adequate Vitamin D in preventing
disease, and find out how you can participate in
a clinical research trial to see if Vitamin D is
protective against COVID-19. That's coming up right now
on, At the Forefront Live. [MUSIC PLAYING] And we want to remind our
viewers that today's program is not designed to take the place
of a visit with your physician. Let's start off with having
each of our investigators introduce themselves and
tell us what you do here at UChicago Medicine. And Dr. Meltzer, you're
actually on set with me, so we're going to
start with you and then we'll go to Dr. Lee
in just a moment. Great. I'm David Meltzer. I'm a Fanny Pritzker
Professor of Medicine and I'm Chief of the section
of Hospital Medicine here. In addition, I run
the Center for Health in the Social Sciences,
which we call CHeSS. Fantastic. And Dr. Lee? I'm Raphael Lee. I'm a Paul and Aileen Russel
Distinguished Service Professor at the University in
Surgery and in Medicine and at Pritzker School
of Medical Engineering I'm a Plastic Surgeon and
a Biomedical Engineer who has spent most of his
career focusing on trauma and trauma-related
problems, such as wound healing and scarring. Fantastic. And we'll talk a little
bit about Vitamin D in wound healing here
in just a moment, which is a fascinating
connection that I think people will be interested in. But let's start off with just
kind of some of the basics. And Dr. Lee, I'm going
to start with you. Talk to us a little
bit about Vitamin D-- what exactly does it do for
the body, why is it important, and why do we need to make
sure we have enough of it? So vitamin D is an
extremely important, fundamentally important
biological molecule that functions much
like the Secretary of Defense for the cell. And it regulates
the immune system. It regulates and
controls the ability of cells to respond to
stress and injury, attacked by offending organisms
like viruses and bacteria, and it really has
an ancient history in the biological system dating
back over 500 million years. And so it's still, even
today, in our complex systems, no longer single cells
like yeast and fungi, but now complex organismal
systems such as a person-- the immune system has
several different components and Vitamin D continues
to play the central role in regulating the body's
response to stress and injury. So its ability as the
single cells in the body to protect itself with
antimicrobial proteins and repair molecules and
controlling inflammation. And then, modifying the part of
the immune system that actually learns from an
offending organism so that it develops antibodies
and get the delayed response. We call that adaptive immunity. So Vitamin D is
really essential, in terms of body function. So how do we get Vitamin D? I think that's the big
question everybody would ask. We think about it, I think
about going out in the sun, but there are other ways. And I don't know, is that the
primary way to get Vitamin D? So the term vitamin
implies that all the vitamin that the source
is through a nutrient. But in fact, we can make--
our bodies can make Vitamin D with the aid of sunlight. The sunlight, cholesterol
is converted in the skin to an active molecule that then
gets converted into Vitamin D. And that happens
with the influence of the ultraviolet
component of the sunlight. And so our skin plays
an important role in regulating how much
vitamin D we make, and also that means that
sunlight exposure is really important and therein lies
where there are differences in the color of skin
and also the changes in human habitat over
the last 100,000 years that human society
existed on Earth. In the last couple
of hundred, we've moved increasingly indoors and
we get less sunlight exposure. There's some advantages to
that, but the disadvantage is that Vitamin D
production is low. Now, the other source
of Vitamin D is dietary. And so plants make a form
of Vitamin D called D2, and then animal
systems like fish make Vitamin D by getting their
precursor from the plants that grow on the surface
of the ocean, which are the main source
of Vitamin D and then they convert that
to a vitamin D3. So today, our primary
source of Vitamin D, particularly for those of us
who live up above the level like St. Louis and north
of that, we don't-- can't get enough
sunlight, so we have to have the dietary
intake and fish and certain kinds of plants-- mushrooms and so forth. And then, of course, we have
Vitamin D fortified milk, and so forth, in
the modern society. Those are really our dietary
sources of Vitamin D. And I was going to say, you
brought up where we live. Chicago is kind of a
difficult place in the winter because it is gray
a lot and so I would imagine you don't get
nearly the Vitamin D levels you would want from the sun. But skin color is also an
important factor in this. People of color tend to get
a little less Vitamin D, is that correct? Yeah. So that's the reason why-- one of the main
reasons why there is variation in skin color. The people that
normally have emerged from parts of the
world that's more equatorial than in
the temperate zone, they need color in their skin,
so not to make too much Vitamin D. But those who have come
from the more northern or more southern regions of the
globe where there's less sunlight and there's
more overcast, they don't have very
much pigment in the skin because they need as
much sunlight as they possibly can to make
Vitamin D, and they've adapted other mechanisms to
control the immune response. Now, I also-- when we talk about
Vitamin D and its function, calcium and bone
metabolism is the thing that comes to mind
first, but calcium plays a key role in regulating
the immune system. And of course, by
regulating calcium, Vitamin D continues to
have this fundamental role in regulating skeletal growth. So in order to have normal
skeletal growth in the more regions of the Earth that's
closer to the equator and regulate the immune system
properly, skin color has to-- more pigment is
needed in the skin. Interesting. So Dr. Meltzer, I
know that you've been studying the relationship
between COVID and Vitamin D and that's been taking over
the news lately, it seems like. We were talking before
the program about just all of the attention that you've
received for the study. Tell us how you got
interested in that and what are you seeing so far? Yeah, yeah. So I had a general
awareness of the importance of Vitamin D for bone
health and that it was important for
immune function, but what really got me
interested in this topic was an article that I saw that
had been published about two years ago that showed that
patients who were randomly assigned to get
Vitamin D supplements had about a 70% reduction
in viral respiratory tract infections. And this-- I saw this
article back in March. At that point,
COVID was brand new. We knew it was caused
by a coronavirus, knew that was a viral
respiratory tract infection. I knew that coronaviruses
are common causes of viral respiratory tract
infections and thought, boy, maybe Vitamin D would work. And so what I did was
I went into the records that we have here in the
hospital for the patients that we've cared
for over the years and I knew that we had a
large group of patients who had Vitamin D levels
that we'd seen in the past and that they were coming
in and getting tested. And so I looked to see
whether those patients who had Vitamin D deficiency and
weren't adequately-- had not adequately been supplemented
were more likely to test positive for COVID. And what I discovered is
that those patients who were, indeed, Vitamin D
deficient and hadn't been treated were almost twice
as likely to test positive for COVID. And that's the
basis of the article that we published in
JAMA Network Open. That's fascinating. We will take questions
from the viewers. We're going to try
to hold some of those towards the latter
part of the program because we have
quite a few questions to get through
that we've already talked through with
our researchers, first. But we will take your questions. So just type them in
the comments section. We'll get to as many
as possible as we can. So talk to us about
differences in race, because we touched on that
with Dr. Lee a little bit just a moment ago, but you're seeing
some pretty marked differences, I would imagine in the study? Yeah. I knew when I started this
that Vitamin D deficiency was much more common in
people with darker skin, and much more common in
areas like Chicago where we don't get much sun. In our original
sample, the majority of patients who were coming in
and getting tested for COVID were African-Americans,
so we knew we had a sample that was
heavily African-American and thought that that might be
the group where we were seeing the biggest effects. But we didn't have enough
cases at that point to really study it. So over time, we
collected more cases. Our original study was
with only 600 cases and most recently, we
published the second study with 3,000 cases. And with the larger
sample size we were able to break things
down by race, and also by level of Vitamin
D. And what we found was that the effects, the
association of Vitamin D deficiency with COVID was much
stronger for African-Americans. And moreover, what we found
was that the risk of testing positive for COVID was
actually increased, even with levels that were above
what is considered adequate. So normally, 30 or above-- 30 nanograms per
milliliter or above is considered an adequate level. And we found that
patients who had levels of 30 to 40 nanograms per
milliliter of Vitamin D actually had a two to three full
times increased risk of COVID compared to patients who had
40 nanograms per milliliter or more. So that made us think
that African-Americans may benefit in terms of
immune function of having even higher levels. We suspect there may be similar
relations for individuals who are not
African-American, as well, and that's something
we're continuing to study. But for now, we see
this strong association for African-Americans. So explain to us how this works. You've done the research
as far as just looking at the association,
and now we're starting a clinical
trial, is that correct? Yeah, that's right. So what we observe is
an association and we control for lots
of other variables that might explain both
the Vitamin D level and why people get
COVID so that we don't think it's confounding,
but we don't know for sure. And so a randomized
trial allows us to take a bunch of individuals
who meet certain eligibility criteria and then consent them. And then allow them
to randomly receive either a low dose or a medium
or a high dose, for example, and then understand whether
they are less likely, indeed, to get COVID, depending
on the dose that they get. Interesting. So how-- you were telling me a
little bit before the program, we do have some folks
already involved, but you would like
to get more, too, so I want to promote that
throughout the program so we can make sure we get that. Sure. Let me tell you a little
bit about the studies. Sure. We're doing we're
doing two of them. The first one is funded
by NIH, and that's a study we're doing jointly with Roche. And there, people come in,
they sign a consent form, they get some labs done to
test their calcium levels and other sorts of
blood levels that might indicate what the right
dose safety for Vitamin D would be. And then, assuming they meet
the eligibility criteria, they're then randomly assigned
to either a low dose of Vitamin D or a medium or high
dose of Vitamin D. And this allows us to tell
whether that medium or high dose is affecting them, compared
to the low dose, in terms of whether they test
positive for COVID over time. And we call them
every few months to see how they're
doing and checking in. So that's a study that's
just in the Chicago area and requires that people come
in either to us or to Roche. The other study we're doing
is completely on the internet. And there, people sign up,
they can go to the website, they type in
answers to questions to make sure that
they're eligible. If they're eligible, we simply
mail them some Vitamin D and then we follow up
with them through surveys over the course of a year and
see what their outcomes are. And that's open to people
anywhere in the US. So that probably answers my
next question, which would be, do I need to be a patient of
UChicago Medicine or Roche to participate? No. Absolutely not. We have had many of
our own patients sign up and of course,
that's wonderful. But we've had lots of people
show interest from elsewhere. And one thing we've
seen is actually people signing up
in groups some time. They see the study, they
get interested in it, they tell their friends, and
they kind of do it together. So we welcome people of course,
who are our own patients, but really anyone
from the Chicago area, and for the
internet-based study-- anyone in the country. Perfect. It's just-- it's
fascinating to me, and it's got to be
really interesting work and very rewarding
from your standpoint. Oh, I mean, this has
been fascinating. There are people who've spent
their entire career studying Vitamin D and I had
not, but now that I learn what there
is in Vitamin D, I really think it's
a fascinating area. And I think potentially
really important in understanding how we're
going to address COVID. Great. And let's bring Dr. Lee
back into the conversation for a moment, as well. And Dr. Lee, you touched on
this a little bit earlier in the program, but
can you talk to us about the best
sources for Vitamin D, because those are
the questions that are coming in from viewers. People want to know what
are the best sources and how much should they take? Well, so today,
in modern society, Vitamin D is quite
available in pharmacies and the over-the-counter
preparations that are usually based on fish oil. You can get them
in various doses. The dosage is in units because
it's not a pure compound, but it is measured
in terms of activity. So if one is-- a typical dose of
Vitamin D traditionally had been somewhere
between 400 and 2,000. And now we know that's
pretty inadequate. You can get pills up to 5,000
or 10,000 units at pharmacy. And of course, as you-- over-the-counter-- and the
amount that you should take, you should really have
a physician's advice because some people have
medical problems that could influence the amount of
Vitamin D they should take. You know, it's interesting
because I know from some folks standpoint, and I'm
in this category, too much sun exposure
is a bad thing. I've had some
significant challenges with that over the years. So the supplement
probably is the way to go for people like that,
I would imagine, and probably dietary changes. But the tricky part
of this, and again a little bit of a discussion
before the program is, it's really kind of
difficult to tell how much you actually need to take. Is that-- would
that be accurate? Yeah. I think it's really
hard to know. The guidelines that led to the
recommendations of 400 to 600 to 800 international units a
day as the recommended daily allowance were based almost
completely on bone health. They really didn't have
any data on how much you need for the immune system. And then, the paper that we
studied or published recently is one of the few that really
ties blood levels of Vitamin D to immune function. But even then, we
don't know for sure that the blood levels
are the right measure. There are theories
that emphasize what's called free Vitamin D--
vitamin D that's circulating in the body but not
bound to Vitamin D binding proteins, which is
most of what's measured, and strong reasons to
believe that simply taking a supplement, even if your
levels don't necessarily go up that much, may be
of independent value. So one of the reasons
in our studies that the basic comparison is
between 400 international units a day and 4,000
international units a day is that we really
don't know, for sure, what the right level is. Nor do we know,
frankly, that the level is the perfect measure. It may be that getting
daily sunlight, that taking a supplement daily,
makes such a big difference. I can't help but
resist pointing out that COVID got so much worse
when it got to the winter. And now, it's getting much
worse in South America as they're approaching winter. So sunlight and the
production of Vitamin D really does seem like
it's quite possible could make a difference. And so that daily
supplementation or daily sunlight,
which unfortunately isn't possible in Chicago
in the winter, at least, unless you're a
very robust person-- getting something daily is
probably a really good idea. And that's one of the
reasons why, in our studies, the control group
with low Vitamin D is actually getting the
recommended daily allowance. It's not that they're
getting no Vitamin D. Interesting. So if somebody had
their COVID-19 vaccine, should they still
take Vitamin D? I imagine there's-- I mean,
there's a lot of other benefits, obviously. Yeah. The truth is we don't know. Obviously, you get a lot of
protection from the vaccine and people should be
getting the vaccine and wearing their masks
and social distancing and all of that. But we know the vaccine
isn't completely protective. And we don't know how long it
will continue to be protective, or what will happen with
some of the new variants that are coming around. To the extent that Vitamin
D is important for enhancing the immune system,
I think there's good reason to believe that
it may be useful in this. And so the eligibility
criteria for our study include people who've
gotten the vaccine. We think we will learn
the most, probably, from the people
who haven't gotten the vaccine because
they're at higher risk, but we welcome the
participation of people, even if they've gotten the
vaccine, because we think the risk is still there and
the potential for benefit is still there. And so, Dr. Lee, I know you're
extolling the benefits-- you're both extolling
the benefits of Vitamin D and that's certainly evident,
but can you take too much? Is there an issue if you
go overboard with it? Well, it's certainly--
it's certainly possible. But as Dr. Meltzer
just pointed out, we are just beginning to get
an insight into what the dose response is and also at what
point the system is overloaded or gets to the point where
there might be a toxic effect. And so these answers
are not there yet. There have been
a lot of concerns about raising serum blood
calcium levels with Vitamin D supplementation. And we found a lot of
those concerns-- in fact, not just we, but the
entire medical community that that's a very
unusual problem unless one has other endocrine issues. So it absolutely is
possible to take too much, but with the doses that
we're talking about here, it's very unlikely
that it is too much. I mean, after all, a
lifeguard working on the beach makes about 20,000
units per hour. Oh, wow. So until we-- the doses
we're talking about are small, compared to what a
person 5,000 years ago working in the field would make
on an hourly basis. Interesting. So we're just learning. Yeah, yeah. That's fascinating. I had no idea. We are getting some
questions from viewers and I want to get
to as many of those as we've got about
nine minutes left. So this one is from YouTube. Thanks for viewing on YouTube. Can people with high Vitamin
D have low antibodies as T cells have already
taken care of infection with the help of Vitamin D? Dr. Meltzer, I don't
know if you want to-- I don't know, or Dr. Lee, would
you like to answer that one? Well, so you know, it really-- so first of all, the
precise answer to that really depends on
the individual. I mean, they have
different effects. I mean, the Vitamin D
turns on the function of certain kinds of immune
cells like the white blood cells and the cells that are on
the surface of the intestines and in the bronchials. These are eosinophils that
have sort of a generalized, predetermined response. But it down regulates a bit
the other type of immunity. Together, it's orchestrated. And you know, this is
an area of expertise where new results are
coming out every year. We don't know the
entire story yet. And I think that's
a great answer. And I'll just add that
one of the things we know about Vitamin D is
it's an immunomodulatory. It doesn't just activate
the immune system, but it prevents it from
becoming over-reactive-- Interesting. --which we know is
a problem in COVID. And there's some
evidence that it also increases the specificity of
response to the immune system. So better targeting the
pathogen without leading to too much inflammation. Interesting. Here's another good question. Does a Vitamin D
lamp help or does it need to be a supplement? I have heard about people
that buy the specific lamps that they put on
themselves when they're at their desk at home all day. Yeah. I think we know that
sunlight works very well. I know that there are Vitamin
D lamps that have been shown to increase Vitamin D levels. I think there are a variety
of brands out there. How well they work, I can't
speak to any specific brand. But you do have to be
careful, of course, because that's
ultraviolet radiation and there are risks
associated with that. So it's definitely
something that's in the realm of things
worth thinking about, but we are studying
supplementation because it's much cheaper
and doesn't have some of the same exposure risks. But as Dr. Lee
said very rightly, there's a lot we don't
know about Vitamin D. And there may be some
hidden advantages to lamps in doing things
like breaking down Vitamin D once it's
already been activated and that needs to
be gotten rid of. Great. Dr. Lee, another
question from a viewer. I'm going to throw
this one to you. Does Vitamin D need to be
combined with other vitamins like K to be effective? No. I mean Vitamin D has-- I mean does require certain
action of other vitamins like Vitamin A to
activate the receptor. But that I think
clearly these things are what's really
fundamentally is required is part of the normal diet. So there's no other
co-factor that's required to take with
Vitamin D for Vitamin D to be effective
in a normal person with a balanced--
on a balanced diet. Interesting. Another question from a viewer. Dr. Meltzer, I'm in
your study with Roche. I'm concerned that I have to
decrease my Vitamin D3 in order to go on your low dose study. I've been on 6,000
IU for 14 years. What effect, if any, will
this have on my levels? Yeah. So in general, if people
are on a dose of Vitamin D that they have been
recommended by a doctor, we recommend that they
stay on that dose. We don't want to disrupt
a plan of care that has worked for someone. On the other hand, if people
are taking a dose on their own and don't know for sure whether
that's a dose that they really need for any reason or
don't have a doctor who's told them that, I think we're
all guessing, in some sense, and being randomized
to a different dose could be a very
reasonable thing to do. As I mentioned earlier,
the level that you measure is informative but
it's not necessarily the key driver of this. We do not know whether
they're taking 400 or 4,000 or 10,000 units will
change outcomes, nor do we know whether it
will change outcomes depending on what your blood levels are. The blood levels are heavily
reflective of the amount of Vitamin D that's bound to
Vitamin D binding protein, and what may be most active and
affecting your immune system is what's called Free
Vitamin D. And although those are correlated, they are
not perfectly correlated and they may vary across people
according to the Vitamin D binding proteins. And the Vitamin D binding
proteins I'll say, differ a lot among people
independent of race, but they also differ
quite a lot across races. And so that may be one
of the important reasons why we're seeing these
different effects in our studies are different associations
with Vitamin D levels by race. So we have about 2 and 1/2
minutes left in the program and I want to talk just a
little bit more about the study so we can really emphasize
that you need more people to join you in your studies. So you're putting out that call
and asking for some help there. Yeah. We are really eager. Ideally, we would enroll 2000
people in each of our studies. In total, across the two, we've
enrolled about 700 so far. So we have a ways to go. They're easy to sign up. There's information
available on the internet. I think there'll be a
URL put up and there's a phone number
available, as well, for people who want to
call the phone number. If you're telling your friends
and don't have the URL with you can simply Google Vitamin
D or a Vit D and UChicago and it'll pop right up
on your website browser and you can find
information there. There's actually a page
that will guide you through thinking about
whether the in-person study or the internet study
might be preferred for you. And you can do that based
on whether you're really eager to have a very
higher dose like 10,000, or you're happy with
the 400 or 4,000 and how practical it is for you
to come in to U of C or Roche to get labs or
whether you prefer to just do it on the
internet and let us mail you some Vitamin D. Great. Well, John, who is our Producer
Director, Executive Director, pretty much wear many
hats and runs the thing, he's been putting
that graphic up a lot. So hopefully we'll get
some folks signed up. And I do want to let
people know, remind people, that the program actually
will live on Facebook so you can always refer back. And if you want to talk
to one of your friends and in your social
circle, you can even send him the link from
Facebook or YouTube, as well. So we'll make sure that we
get that information out to as many people as possible. This it's really interesting. Oh, great. Thanks. It's been fascinating
to study and I really hope it makes a difference
in COVID and beyond, because I think Vitamin D
is of fundamental importance for our immune
systems, in general. And we're going to need those
even when COVID is gone. And I got a message that
somebody watching just signed up. Oh, that's great. I'm thrilled. We've got at least one. So that's good. That's a big success. I'll take it. That's awesome. Thank you so much
for doing this. And Dr. Lee, thank you so much
for taking time out of your day today to do this. We really appreciate both
of you coming in here. You're welcome. Great. Thank you so much. So we are out of time. Special thanks to
our physicians, obviously, for being with
us today and researchers. And a big thank
you to those of you who watched and participated
in today's program. You had some really
wonderful questions. Please remember to check
out our Facebook page for our schedule
of programs that are coming up in the future. And to make an appointment
with one of our doctors you can go at
UChicagoMedicine.org or you can give us a
call at 888-824-0200. Thanks, again, for
being with us today. And I hope everyone
has a great week. [MUSIC PLAYING]
