Vitamin D Deficiency
and
Body Aches, Pains And
Chronic Fatigue Syndrome
Body aches, pains and chronic fatigue are the most common complaints that doctors hear from their patients. While there are many reasons why people develop body aches, pains and fatigue, one common and easily treatable cause is vitamin D deficiency. Unfortunately, it often remains undiagnosed and untreated. Consequently, people continue to suffer from chronic pains and fatigue for many years.
The Link Between Vitamin D Deficiency And Body Aches, Pains and Chronic Fatigue
Vitamin D has a close relationship with another hormone known as Parathyroid Hormone (PTH) which is produced by the parathyroid glands, four tiny structures lying low in the neck behind the thyroid gland.
Under normal conditions, PTH is important in maintaining a normal level of calcium in the blood, which is important for the normal functioning of each and every cell in the body, particularly muscle cells and heart cells. PTH maintains a normal level of calcium in the blood by acting on the kidneys, bones and intestines. By acting on the kidneys, it prevents excessive loss of calcium in the urine. It also helps the kidneys convert 25 (OH) vitamin D into 1,25 (OH)2 vitamin D, which then acts on the intestines and helps in the absorption of calcium and phosphorus into the blood stream. By acting on the bones, PTH dissolves their calcium and brings that calcium into the blood stream.
In people with vitamin D deficiency, the parathyroid glands start to produce more than the normal amount of PTH. Large amounts of PTH then cause excessive dissolving of calcium from the bones. Consequently, bones become weak. These people then start to experience bone aches and pains, which are diffuse and deep. People often can’t describe them precisely, but say things like:
“Doc, my whole body hurts.”
“It hurts all over.”
“My body just aches. I feel like someone pulled the plug.”
But sometimes, patients can describe these pains with precision: “Doc, this pain feels deep, as if my bones are aching.”
As a result of generalized aches and pains, you also feel tired and fatigued. You may feel like taking a nap in the afternoon. Typically, you visit your family physician who puts you on pain medications and runs a bunch of expensive tests, which often turn out to be normal. You are then referred to a number of specialists who order more special diagnostic tests. Results of all these tests are often normal as well. Meanwhile, no one orders a test for vitamin D and PTH and therefore, your true diagnosis remains elusive. Some specialist may give you the diagnosis of Fibromyalgia, Chronic Pain Syndrome or Chronic Fatigue Syndrome. This simply describes your symptoms in fancy medical terminology, but obviously doesn’t get to the root of your problem.
You and your physician are perplexed. What’s really causing these pains? “It must be in your head.” Your doctor suggests an anti-anxiety/anti-depression medication. You may actually be anxious and/or depressed because of your frustration. After all, you’ve undergone extensive testing and yet no one really knows what’s wrong with you. You start thinking the worst: “Maybe it’s some cancer they haven’t diagnosed yet.” It’s understandable if you’re anxious or depressed.
By this time, you’re willing to accept any diagnosis. So you buy into any explanation your physician offers. I have heard all kinds of interesting explanations given to patients by their physicians. Here are some examples:
“Your aches and pains are due to anxiety and depression.”
“It’s just from getting old!”
“You have fibromyalgia.”
“You have Chronic Fatigue Syndrome”
“You’re suffering from frailty.”
So your physician puts you on anti-anxiety/anti-depression medications in addition to the pain killers you’re already taking. Each drug may cause some side-effects. Often you develop new symptoms for which you’re given a new medication and then you experience their side-effects. A vicious cycle sets in.
Before you know it, you’re on a long list of medications and still having a lot of symptoms, including generalized aches and pains. Because these medications give temporary relief of your symptoms, you get attached to them. You start to think you can’t live without them. You go from physician to physician looking for pain and anti-anxiety medications, which sooner or later, they refuse to refill. Eventually, you may be referred to a pain specialist. Now you are in for some heavy duty pain medications and sometimes, your pain specialist recommends complicated procedures aimed at treating your Chronic Pain Syndrome. These pain medications are often narcotics with potential for addiction and many other serious side-effects. Over the years, I have seen many such unfortunate messed up cases.
In medical literature, there are several studies which clearly demonstrate that patients with chronic muscles aches and pains continue to suffer simply because their physicians fail to diagnose vitamin D deficiency as the root cause of their symptoms. In one such study (1), researchers investigated vitamin D level in patients with chronic muscle aches and pains at a university-affiliated clinic in Minneapolis, Minnesota, USA. They were amazed to find out that nearly all of their patients were low in vitamin D. Many had severe deficiency of vitamin D. Some had been seeing doctors for years and vitamin D deficiency was not even considered as a cause of their disabling symptoms.
Perhaps now, you realize how frequently physicians miss the diagnosis of vitamin D deficiency as the root cause of chronic muscle aches and pains. Therefore, you have to be proactive in taking charge of your health. Get your vitamin D level tested and get on the proper dose of Vitamin D! (See Chapters 25 and 26 on Diagnosis and Treatment of Vitamin D Deficiency) I have many patients in my practice whose body aches and pains simply disappeared after proper replacement of vitamin D.
Secondary Hyperparathyroidism
When vitamin D deficiency goes undiagnosed and untreated, PTH level in the blood becomes elevated. In medical terms, we call it secondary hyperparathyroidism . Your blood calcium level is normal at this stage of your disease of chronic vitamin D deficiency. Physicians generally don’t order a PTH test when your calcium level is normal. That’s what they were taught in medical schools! Therefore, secondary hyperparathyroidism often remains undiagnosed.
Unfortunately, this high level of PTH comes with a price. It erodes your bones, causing them to ache. Medically speaking, we call it osteomalacia . In plain language, your bones are weak, they ache and they can also easily fracture.
Therefore, if you have bone pains, muscle aches, or chronic fatigue, make sure you get a 25 (OH) vitamin D blood test and a PTH blood test, even if your blood calcium level is normal.
Treatment Of Secondary Hyperparathyroidism
Secondary hyperparathyroidism is due to vitamin D deficiency. Obviously, you treat this condition with vitamin D supplementation. Surprisingly, I have seen patients whose parathyroid glands were inappropriately surgically removed to treat their secondary hyperparathyroidism.
In a study (2) from Helsinki University Central Hospital, Finland, researchers performed a statistical analysis of 52 published clinical trials, including 72 intervention groups and 6290 patients. They found an inverse relationship between vitamin D level and PTH level. In other words, the lower the vitamin D level, the higher the PTH level. They also found that PTH level decreases in a linear fashion during vitamin D supplementation. In other words, as vitamin D level goes up, PTH level comes down proportionately.
I have similar experience at the Jamila Diabetes and Endocrine Medical Center. Here is a case study to illustrate these points:
Case Study
A 61 year old Caucasian female consulted me for Hyperparathyroidism and Osteoporosis. Her primary care physician had put her on Actonel, without ever checking her vitamin D level. She stopped taking Actonel after she read its potential horrendous side-effects.
She had a history of breast cancer, diagnosed 5 years ago, for which she underwent breast surgery and radiation. She had seen several physicians, and none of them mentioned anything about vitamin D. After reading my book, “Power of Vitamin D,” she became aware of the benefits of vitamin D and started to take 1000 IU of Vitamin D3 per day. When she consulted me, she was having fatigue, and generalized body aches and pains. I checked her blood levels of vitamin D. PTH and Calcium, which were as follows:
25 OH Vitamin D = 32 ng/ml (Normal range: 30-100)
PTH intact = 101 pg/ml (Normal range: 14-72)
Blood Calcium = 10.3 mg/dl (Normal range: 8.6-10.4)
I diagnosed her with Secondary Hyperparathyroidism due to vitamin D deficiency. Even though vitamin D at a daily dose of 1000 IU had brought her vitamin D level at the low normal range, it was still low for her, which caused an elevation in her PTH level. Secondary Hyperparathyroidism was the main reason for her osteoporosis.
Over the next two years, I gradually increased her dose of Vitamin D to 20,000 IU per day. Her PTH level has come down into the normal range as her vitamin D level rose into high normal range.
Here are her Progress Notes:
|
|
Baseline |
1 year |
2 year |
|
25 OH Vitamin D
|
32 |
48 |
93 |
|
PTH, intact
|
101 |
78 |
50 |
|
Calcium
|
10.3 |
10.0 |
10.3 |
|
Daily Dose of Vitamin D3 |
1000 IU |
15,000 IU |
20,000 IU |
As you can see, her PTH and blood calcium levels have stayed in the normal range on high doses of vitamin D. She feels great. No kidney stones. No aches or pains. No bone fractures.
Her primary care physician, on his own, decided to order a parathyroid scan, which turned out to be normal. There was no tumor of the parathyroid gland.
Tertiary Hyperparathyroidism /
Primary Hyperparathyroidism
If vitamin D deficiency and resulting secondary hyperparathyroidism is not properly treated, eventually, one or more of your parathyroid glands may get enlarged from all the overwork they have to do. At this stage of chronic vitamin D deficiency, your blood calcium level also becomes elevated . I call this advanced stage of chronic vitamin D deficiency tertiary hyperparathyroidism . Tertiary means that your disease has progressed from secondary hyperparathyroidism to a more advanced stage. However, traditionally, it is called primary hyperparathyroidism .
Typically, a physician is trained to order a blood level of PTH in a patient with elevated calcium level in the blood. If PTH turns out to be high, the patient is diagnosed with primary hyperparathyroidism. As a knee jerk reflex, the patient is then sent for parathyroid surgery.
I have a problem with this terminology of primary hyperparathyroidism, because it implies that your PTH level became elevated for some unknown reason. With this mind set, physicians, even at this advanced stage of the disease, don’t order a vitamin D level. This terminology of primary hyperparathyroidism comes from the era when we did not test our patients for vitamin D deficiency as we do now. Unfortunately, most physicians remain stuck in their old way of thinking.
My belief is that most cases of primary hyperparathyroidism are actually tertiary hyperparathyroidism, the result of years and years of untreated vitamin D deficiency. With early diagnosis and treatment of vitamin D deficiency, we should be able to prevent a large number of these cases of so called primary hyperparathyroidism.
Rarely, blood level of calcium and PTH are elevated despite an optimal level of vitamin D. These are the true cases of primary hyperparathyroidism. What is an optimal level of vitamin D? Please refer to Chapter on Treatment of Vitamin D Deficiency. It’s interesting to note that the prevalence of primary hyperparathyroidism has increased tremendously in the last three decades. This precisely coincides with the widespread usage of sunscreen lotions and an epidemic of obesity, both of which have contributed to the epidemic of vitamin D deficiency.
Combined Primary Hyperparathyroidism
And Secondary Hyperparathyroidism
Even in these true cases of primary hyperparathyroidism, there is often a component of secondary hyperparathyroidism, which is easily treatable with vitamin D. Consequently, with proper vitamin D supplementation, your PTH level comes down, although it may not get into the normal range.
In general, when you are diagnosed with Primary Hyperparathyroidism, your physician often does not even bother to investigate your vitamin D level. Hence, your vitamin D deficiency remains undiagnosed with all of its negative consequences. Often, you are even given the advice to stop taking vitamin D, as your physician is afraid that vitamin D will further increase the calcium level in your blood. The reality is actually quite opposite.
In a study (3) from Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals in the UK, researchers observed forty consecutive patients with primary hyperparathyroidism and coexistent vitamin D deficiency. They found that those patients who were treated with vitamin D had a significant drop of 21% in their PTH level, compared to those who did not receive vitamin D. They followed these patients up to 54 months and found treatment with vitamin D to be safe, without any increase in the calcium level in the blood or any detrimental effects on the kidneys.
When To Consider Parathyroid Surgery
In the late stage of parathyroid disease (tertiary or primary hyperparathyroidism) due to chronic vitamin D deficiency, if your blood calcium remains elevated above 11 mg/dl even after you have achieved an optimal blood level of vitamin D (discussed in Chapter 26, on Treatment of Vitamin D Deficiency), you should consider parathyroid surgery.
Some people with elevated blood calcium level may also develop kidney stones. These patients should have parathyroid surgery. High calcium in the blood leads to high spillage of calcium in the urine and consequently, increases your risk for calcium stone formation in the kidneys. This high spillage of calcium in the urine can be easily diagnosed with a test ordered by your physician. In this test, called 24 hours urine for calcium, you collect your urine for 24 hours and take it to the laboratory for calcium testing. Contact the laboratory in advance for special instructions as well as a special bottle to collect your urine.
If you have high blood calcium, high PTH level and your 24 hours urine calcium is more than 300 mg, you are at high risk for calcium stone formations in the kidneys. You may consider parathyroid surgery even if you don’t yet have kidney stones.
Some patients with tertiary (primary) hyperparathyroidism may develop severe osteoporosis and are at risk for fracture of their bones. They should also consider parathyroid surgery.
You Need Vitamin D Replacement Even After Parathyroid Surgery
Parathyroid surgery does not treat the disease itself: vitamin D deficiency. Symptoms of vitamin D deficiency such as body aches, pains and chronic fatigue are not going to go away just by doing parathyroid surgery. Many physicians are not aware of this fact. Typically, patients undergo parathyroid surgery, but still no one orders vitamin D level. Please remember that even after parathyroid surgery, you will need proper replacement with vitamin D.
Perhaps now, you can understand why an early diagnosis and proper treatment of vitamin D deficiency can save you from a lot of misery. You can prevent body aches, pains, osteoporosis, kidney stones and parathyroid surgery.
References:
1. Plotnikoff GA, Quigley JM. Prevalence of severe hypovitaminosis D in patients with persistent, nonspecific musculoskeletal pain. Mayo Clin Proc . 2003;(78):1463-1470.
2. Björkman M, Sorva A, Tilvis R. Responses of parathyroid hormone to vitamin D supplementation: a systematic review of clinical trials. Arch Gerontol Geriatr . 2009 Mar-Apr;48(2):160-6
3. Rao RR, Randeva HS, Sankaranarayanan S, Narashima M, Möhlig M, Mehanna H, Weickert MO. Prolonged treatment with vitamin D in postmenopausal women with primary hyperparathyroidism. Endocr Connect. 2012 Jun 8;1(1):13-21.