生物与医学2020ncbi.nlm.nih.gov
维生素 D 的巨大错误（2017）
The Big Vitamin D Mistake (2017)
入门 · 约 45 分钟读完前置知识：营养学基础、观察性研究与随机对照试验的区别
导读
这篇 2017 年的论文认为，长期以来推荐的维生素 D 摄入量和血清 25(OH)D 目标水平定得过低，导致大多数人处于维生素 D 不足状态，主张大幅提高补充剂量以降低多种疾病风险。文章依据血清 25(OH)D 水平与全因死亡率的关联等观察性证据来支持补充维生素 D。
HN 关注点：维生素 D 补充剂在 HN 读者中极受欢迎，但观察性关联与随机试验结果之间的矛盾（补充是否真正降低死亡率）一直是争论焦点。
HN 评论精选
这几条评论里：质疑 2 补充 1 亲历 1
质疑最新随机试验荟萃分析显示补充维生素 D 并不降低全因死亡率，它可能只是标志物而非病因
虽然我总体上很支持补充维生素 D，但要注意：这篇论文引用血清 25(OH)D 水平与全因死亡率关联的荟萃分析来论证补充的必要性，但更新的荟萃分析（Zhang 等，BMJ 2019，n=75,454）显示，单纯补充维生素 D 与成人全因死亡率降低并无关联，仅使癌症死亡风险降低 16%。如果如此，维生素 D 可能主要是不良结局的标志物，而非真正的病因。
lhl查看英文原文
While I'm a big fan of Vitamin D in general, one thing to watch out for is that while this paper cites meta-analysis of associations of serum levels of 25(OH)D and ACM as an argument for supplementation: Garland, Cedric F., June Jiwon Kim, Sharif Burgette Mohr, Edward Doerr Gorham, William B. Grant, Edward L. Giovannucci, Leo Baggerly, et al. “Meta-Analysis of All-Cause Mortality According to Serum 25-Hydroxyvitamin D.” American Journal of Public Health 104, no. 8 (August 2014): e43–50. https://doi.org/10.2105/AJPH.2014.302034. Recent meta-analysis seems to suggest that supplementation is not associated with lower ACM. In that case, Vitamin D would be primarily a marker for poor outcomes, not the actual primary cause. n=75,454 "Vitamin D supplementation alone was not associated with all cause mortality in adults compared with placebo or no treatment. Vitamin D supplementation reduced the risk of cancer death by 16%. Additional large clinical studies are needed to determine whether vitamin D3 supplementation is associated with lower all cause mortality." Zhang, Yu, Fang Fang, Jingjing Tang, Lu Jia, Yuning Feng, Ping Xu, and Andrew Faramand. “Association between Vitamin D Supplementation and Mortality: Systematic Review and Meta-Analysis.” BMJ 366 (August 12, 2019): l4673. https://doi.org/10.1136/bmj.l4673. 2011 Discussion on Vitamin D as a marker: Jacobs, Elizabeth T., María Elena Martínez, and Peter W. Jurutka. “Vitamin D: Marker or Mechanism of Action?” Cancer Epidemiology, Biomarkers & Prevention : A Publication of the American Association for Cancer Research, Cosponsored by the American Society of Preventive Oncology 20, no. 4 (April 2011): 585–90. https://doi.org/10.1158/1055-9965.EPI-10-1257.
补充医生对维生素 D 剂量的建议混乱且互相矛盾，患者很难获得一致指导
真希望维生素 D 的科学结论能更明确一些。我因甲状腺功能减退被医生要求每天服 7000 IU，但连这位医生自己有时都会忘记我已在服药、给出另一个剂量，我说明后他只说"嗯……我觉得差不多"。其他医生更糟：有人认为 7000 IU 有毒而反对我服用；我解释甲减患者即使血清水平正常也可能表现出缺乏症状、需要把水平推到高于正常才能缓解，医生们的反应也五花八门——有人愿意去查资料，有人生气，也有人认同。
speeder查看英文原文
I wish the Vitamin D science was more nailed down. I am currently taking 7000 UI daily, because medic told me to do so, thing is... even the same medic, sometimes told me to take another dose, because he forgot I was already taking it, when I told him what I was taking, his reply was... "huh... that I think is about right". My experience with other medics weren't better. Also some were AGAINST me taking Vitamin D, because 7000 UI is viewed by many medics as toxic, but I have hypothyroidism, and one of its issues is that some people show vitamin D deficiency symptons even with correct blood serum levels (and the symptons go away only after forcing the levels go higher than normal), telling that to medics also resulted in mixed results, some said they would read more, some got mad at me, some agreed with me.
亲历亲历：即使大量日晒也难以达到理想血清水平，室内工作者只能靠补充剂
今年夏天我花了约六周尽量多晒太阳：每天穿短裤赤膊遛狗 20-30 分钟，每周还赤膊骑行几次，不服用补充剂，也不吃强化维生素 D 的食物。最后用邮寄检测测得 40 ng/mL，按某些标准只是可接受范围的下限。赤膊走路感觉很怪，多数人恐怕不愿这么做；而且太平洋西北地区即将进入雨季，根本晒不到太阳。对像我这样在室内工作的人来说，补充剂似乎是维持健康水平的唯一选择。我现在每天服 5000 IU，几个月后再测。主观上感觉比几个月前好多了，但可能是安慰剂效应。总之我确信自己应该补充维生素 D。
mikenew查看英文原文
This summer I spent about six weeks making an effort to get as much sun exposure as I realistically could. I'd do 20-30 minute dog walks in the afternoon in shorts and no shirt, plus a few bike rides per week, also shirtless. I didn't take any vitamin D supplements and, as far as I know, wasn't eating any food with added vitamin D like milk. At the end of it I did one of those mail-in vitamin D tests, and it put me at 40 ng/mL. Depending on the source, that's very bottom edge of the acceptable range. Walking around with your shirt off feels pretty weird, and I can't imagine most people would even be willing to do that. And of course it's getting into the rainy season here in the pacific northwest, so there's no sun exposure to be had no matter what you do. Seems like, at least for someone like me who works indoors, supplementing is the only option to stay within a healthy range. I figure humans are just not adapted to wearing a lot of clothing and staying indoors all the time. I'm now taking 5000 IU per day, and I plan to take another test in a few months. Subjectively I can say that I feel far better than I did a few months ago, but that could be placebo or due to other factors. Still, I'm pretty convinced I should be supplementing vitamin D.
质疑引用另一篇 HN 讨论的文章质疑高剂量补充的安全性，并询问 nmol/L 与 ng/ml 的换算
不到两个月前 HN 上刚讨论过一篇博客（devaboone.com 关于维生素 D 的文章），似乎与本文直接矛盾：文中患者每天服 5000 IU 五年后血维生素 D 升至 79 ng/ml，虽在许多实验室的"正常范围"（30-100 ng/ml）内，但作者见过 70-100 ng/ml 之间的中毒案例，认为更合理的正常范围是 30-60。另外，链接的论文似乎用的是 nmol/L 单位而非 ng/ml，乘以 2.5 换算似乎对不上，有懂行的人能解释一下这两个单位吗？
zzzeek查看英文原文
not even two months ago there was a big HN discussion about a blog post, including comments here by the author: https://www.devaboone.com/post/vitamin-d-part-2-shannon-s-story?postId=5f39453f8d01fe00170023fe which would appear to contradict this article quite directly, if I'm reading correctly (I'm a know-nothing here taking 2000 iu /day, just trying to understand the topic)? "Her Vitamin D was low at the time, so her physician started her on over-the-counter Vitamin D supplementation at 5000 international units (IUs) daily. Five years later, she was still on this dose, and her blood Vitamin D level had risen to 79 ng/ml. This level is within what many labs call the normal range, between 30 and 100 ng/ml, but levels above 70 are almost always a result of high dose supplementation, and I have seen toxicity with levels between 70 and 100 ng/ml. (A better “normal range” based on what I have seen would probably be between 30 and 60.) " The linked article seems to be using nmol/L units as opposed to ng/ml so multiplying by 2.5 doesnt seem to be working out for me, someone who knows something have any comparison between these two?
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