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It all started," says Prof. Sophia Ish-Shalom, "when students of Prof. Aron Troen from the Faculty of Agriculture, Food and Environment at the Hebrew University in Jerusalem, drew up a summary of the existing studies on vitamin D. They went to him and said: ‘Look, you need to address the issue of vitamin D insofar as it relates to the coronavirus crisis.’ And then we all met up on Zoom, together with Prof. Ronit Endevelt, head of the Health Ministry’s Nutrition Division, and a fellow professor from the United States who’s studying the issue, and in April, we published the first document on the subject."

Ish-Shalom, vice-chair of the Israeli Foundation for Osteoporosis and Bone Diseases, is an endocrinology specialist and long-time leading researcher when it comes to vitamin D. As early as 2011, for example, she led a study that found low levels of vitamin D among employees in the hi-tech industry and examined the effect of supplements on this population segment. Over the past few months, she’s been serving as a consultant to the Health Ministry regarding its instructions to the public concerning vitamin D. In the coming days, the ministry is expected to release a new document on the subject.

Ish-Shalom is far from being the only researcher who’s been studying vitamin D and its interaction with COVID-19. Since the outbreak of the pandemic, an increasing number of researchers have claimed that the vitamin can be beneficial in the fight against the virus, both in terms of the scope of the infection and the severity of the symptoms. The issue was bumped up a notch this past weekend with the publication of a comprehensive report by the National Coronavirus Information Center - a new body established and operated by IDF’s Military Intelligence division, the National Security Council and the Health Ministry - which reviewed several studies into the correlation between vitamin D and the progress of the disease and the mortality rates among those who are infected with the virus. The bottom line is clear: The public should be advised to take vitamin D supplements.

Preventive medicine is a cornerstone in the management of public health, and the Health Ministry’s first public announcement recommending the consumption of vitamin D was published as early as April, only to be quickly swallowed up among the avalanche of reports about the crisis. Months have passed since then; the first wave has come and gone, and the lockdown imposed due to the second wave is also on its way to being partially eased. Nonetheless, despite the ever-increasing evidence regarding vitamin D, the Health Ministry has failed to launch any kind of campaign promoting its consumption. There have been public service announcements, accompanied by somber background music, warning of the dangers of the coronavirus and urging citizens to wear masks, avoid public gatherings and maintain social distancing - but there’s been no effective information campaign that calls on the public to get a moderate dose of sunshine or take vitamin D supplements to boost physical (and mental) resilience. At a time when more and more evidence from around the world points to the importance of exposure to the sun and spending time in the open air during the warm daylight hours, people are increasingly likely to be shut off at home and staying away from parks and beaches.

One way or another, the vacuum created by the Health Ministry’s failure to offer the public guidance has been filled by various voices, at least some of which are not qualified to offer advice on the subject, and the public has dipped into its pockets, telling itself that, even if it doesn’t help, it can’t do any harm. This is clearly evidenced by the shortages on the shelves of some of the more popular vitamin D supplements. Moreover, following the consumption recommendations of these self-proclaimed experts can also be problematic and even dangerous - on which, more later.

The Health Ministry’s first announcement recommending the consumption of vitamin D was published as early as April, only to be quickly swallowed up among the avalanche of reports about the crisis. Months have passed since then; the lockdown imposed due to the second wave is also on its way to be eased. Nonetheless, despite the ever-increasing evidence, the Health Ministry has failed to launch any kind of campaign promoting its consumption.

"You can expose your bare arms to the sun even without straying more than the mandated 1000 meters from your house," says Prof. Endevelt, adding that she also takes a vitamin D supplement. "Someone like me, who doesn’t see the sun and sits in an office, should take a supplement. We published a position paper on the subject as early as April, and we’ll be releasing an updated advisory in the coming days. I’d like to stress the importance of maintaining a healthy nutritional status in general, and not just when it comes to vitamin D. Maintain nutritional fitness, eat healthily, and don’t be overweight or underweight. Nutrition is a significant component in terms of the chances of recovery from the virus."

So what kind of information campaign are you conducting?

"We’ll be issuing our recommendation in the coming days, and what you do with it in the media is important."

Asked whether the ministry will be airing infomercials on the subject or conducting a structured campaign to promote it, Endevelt says the matter will be taken up with the ministry’s public relations officials. A simple blood test is all it takes to detect a vitamin D deficiency, Endevelt says in response to another question, quickly adding: "But most of the population has a vitamin D deficiency - between 50 and 70 percent of the population, depending on the sector. It wouldn’t hurt, therefore, for most people to take a vitamin D supplement."

The ministry knows, the public doesn’t

Health authorities have known for years that around 70 percent of the Israeli public suffers from a vitamin D deficiency, and that figure itself isn’t particularly unusual in global terms: A significant proportion of the world’s population lacks the vitamin for two main reasons - insufficient exposure to UV radiation (sunshine), and insufficient vitamin D consumption in our diets. The deficiency is sometimes so severe that it exposes the population to various pathologies, such as osteomalacia (softening of bones) in young children and adults, and leaves people more at risk in terms of contracting respiratory infections and viral diseases (like the coronavirus).

The report from the National Coronavirus Information Center refers specifically to the link between vitamin D deficiency and COVID-19 morbidity, noting, for example, that vitamin D deficiency is widespread in the United States among the general population, and among the black and Hispanic sectors in particular - two groups highly represented among symptomatic coronavirus patients. In Israel, vitamin D deficiency is particularly widespread among the ultra-Orthodox and Arab populations, two sectors which also have very high COVID-19 morbidity rates.

The daily conduct of these two population sectors, as different as it may be in relation to the general population, isn’t enough to explain the high morbidity rates, and one needs to look at studies that have focused on the link between vitamin D levels and the coronavirus from various perspectives. One such study examined the link between vitamin D levels in the blood and immune system responses (infection), and the link between vitamin D levels in the blood and the progression of the coronavirus illness (severity, extent of hospitalization, and mortality). The document reviews no fewer than 19 studies conducted over the past six months in various countries, including Ireland, Italy, Spain, Germany, the Philippines, the United Kingdom, the United States and Iran. Two studies were conducted here in Israel - one at Bar-Ilan University, in collaboration with the Leumit HMO, and a second, by the Clalit HMO, which was published in September but failed to make waves in the media.

The study found a correlation between low levels of vitamin D and contracting the coronavirus. Even after adjusting for age, gender, socioeconomic status and underlying illnesses, the risk factor is 1.5 times higher. And it doesn’t end there: The study also found that people with low levels of the vitamin are twice as likely to develop more severe symptoms.

The Clalit study examined data collected between 2010 and 2019 from 1,359,339 of the HMO’s patients who underwent tests to determine the vitamin D levels in their blood. The researchers reviewed the extent and population type of those who exhibited a moderate vitamin D deficiency (30-50 nmol/L) and those who showed a severe deficiency of the vitamin (less than 30 nmol/L), finding that the deficiencies exist in the population in general (see table), but are more common among the Arab and ultra-Orthodox sectors, and Arab women in particular, with 81.5 percent showing a low to moderate deficiency of the vitamin, and 59.1 percent a severe deficiency. For the sake of comparison, just 11 percent of the total number of women tested during the period in question exhibited a severe deficiency - less than a fifth when compared with the numbers among Arab women specifically. Among Arab men, 60.8 percent exhibited a severe vitamin D deficiency - almost double the proportion among the male population in general (34.1 percent). High rates of deficiencies were found among the ultra-Orthodox population, too, albeit not as high as those in the Arab sector, with 57.3 percent of ultra-Orthodox women and 51 percent of ultra-Orthodox men exhibiting a low-to-moderate or severe vitamin D deficiency. Among the ultra-Orthodox, too, the numbers are high in comparison with the general population, particularly when it comes to severe deficiencies; the numbers in this regard are more than double those in the general population. Even if these figures don’t point to an unequivocal link between vitamin D levels and coronavirus morbidity rates in the two sectors, information on the importance of the vitamin is clearly urgently required, particularly among those populations in which the deficiency rates are very high.

The study at Bar-Ilan University, in collaboration with the Leumit HMO, involved 7,807 subjects whose vitamin D levels had been tested and who were also tested for the coronavirus. Out of the total number of subjects, 782 (approximately 10 percent) tested positive for COVID-19. The study found a positive correlation between low levels of vitamin D in their blood (less than 20 nmol/L) and infection with the coronavirus, with the deficiency constituting a statistically distinct risk factor (a 1.5 times higher chance of contracting the disease even after adjustments for age, gender, socioeconomic status and underlying illnesses). And it doesn’t end there: The study also found that people with low levels of the vitamin are twice as likely to develop more severe symptoms and require hospitalization. The researchers note that the results of the study correspond with those of similar studies conducted in the past, but that the nature of the vitamin’s defense and activation mechanisms has yet to be determined.

These studies have demonstrated a circumstantial link between low levels of vitamin D and coronavirus mortality and morbidity rates, but their weakness stems from the fact that almost all of them have been observational rather than interventional. An observational study is one that points out the need for interventional research (i.e. active intervention in the form of prescribing a vitamin D supplement and examining the effects). Such studies, however, hardly exist. "There isn’t a field in which studies into links with vitamin D haven’t been conducted, from bone health to ovulation and fertility, and through to viral diseases and the coronavirus, but they’re all observational studies; they only allude to a need to investigate - in the same way a court doesn’t decide someone’s fate based on circumstantial evidence alone," says Ish-Shalom. "Unfortunately, because we’re talking about a nutritional component, or lifestyle component, there isn’t much funding for research, so the studies are primarily observational."

One of the studies that appear in the National Coronavirus Information Center report is an interventional study. It was carried out at the Hospital Universitario Reina Sofia, in Córdoba, Spain, on a small group of 76 coronavirus patients who were divided into two groups, with one group taking vitamin D supplements and the other not. The study found that members of the group that took the vitamin were 96 percent less likely to require intensive care treatment. The study, however, has been challenged, with detractors criticizing the small number of subjects and also the fact that the vitamin D provided to the subjects was an activated supplement that isn’t available to the public in stores and isn’t the same as the vitamin D absorbed during exposure to the sun.

One of the studies that appear in the report is an interventional study. It was carried out in Spain, on a small group of 76 coronavirus patients who were divided into two groups, with one group taking vitamin D supplements and the other not. The study found that members of the group that took the vitamin were 96 percent less likely to require intensive care treatment.

Underway at present, according to the report, are 35 clinical trials, some of them interventional, which deal with the link between vitamin D levels and the severity of the Corona disease, its progression, treatment and prevention.

Despite the lack of interventional studies, the report presents a long list of recommendations that have been sounded worldwide (and in Israel) regarding the consumption of vitamin D supplements during the coronavirus crisis. In Israel, the current situation aside, the Health Ministry recommends vitamin D supplements for all persons over the age of 65, as well as infants, children and adolescents. In April, as mentioned, and after the outbreak of the pandemic, the Healthy Ministry published updated nutritional guidelines for the entire population, advising people to maintain a proper level of vitamin D by spending a cumulative 20 minutes a day in the sun, between 11 A.M. and 4 P.M., or by taking a daily supplement containing 800-1,000 International Units of vitamin D, with the latter aimed primarily at the elderly and people who don’t get much sun.

These guidelines also refer to a position paper that recommends, in light of the pandemic, a daily supplement of 1,000-2,000 IU of vitamin D for the general population. Furthermore, a position paper on the subject published by the Israeli Pediatrics Association at the end of April recommends brief daily exposure to the sun and 1,000 IU of vitamin D per day for all children, from the age of one, for six weeks, together with a policy of enriching milk with vitamin D.

The bottom line of the center’s review of the subject is essentially depressing. The Health Ministry has been aware of the issue for years; its experts and other doctors in Israel recommend taking vitamin D supplements. This important information, however, has barely trickled down to the public, and most of the population remains unaware, or worse even, views the matter as controversial.

Watch the dosage

Because vitamin D is a supplement that doesn’t require a doctor’s prescription and can be acquired in uncontrolled quantities, the need to carefully and clearly explain to the public the extent of its use becomes even more critical. And the same goes for exposure to the sun.

"There’s a severe deficiency of vitamin D among the public in Israel, there’s no doubt about that," says one researcher. "As a researcher in the field of public health, I can present a lot of articles, publications and studies, but they don’t carry the same weight as an official Health Ministry public advisory, which needs to be very carefully worded. If they advise people to spend time in the sun, some people could think they need to sit in the sun for four hours covered in baby oil. Scientific knowledge doesn’t always translate into proper application among the public, and that’s how we end up with very low levels of vitamin D in the population."

Ish-Shalom, who assists the Health Ministry with its publications, is of the same mind. "The public perceives the issue of vitamin D in terms of the more, the better - and that’s not the case," she says. "Excess intake and overdosing are dangerous. We have a WhatsApp group for the country’s leading endocrinologists, for example, and one of the doctors told the group that she saw a patient who had been drinking a vial of vitamin D every day, on the understanding that it was a good thing to do at this time, and ended up with excess levels."

Ish-Shalom, who assists the Health Ministry with its publications: "The public perceives the issue of vitamin D in terms of the more, the better - and that’s not the case. Excess intake and overdosing are dangerous. one of our doctors told us that she saw a patient who had been drinking a vial of vitamin D every day, on the understanding that it was a good thing to do, and ended up with excess levels."

Is this happening because the guidelines aren’t clear and people are confused?

"Yes. One of the biggest problems in Israel is that the two HMOs [mentioned in the report] use different scales of measurement for vitamin D, which leads to confusion. Someone does a blood test and gets a result but doesn’t pay attention to the unit of measurement. They panic and immediately read an article on the internet in which the information could refer to a different unit of measurement, and chaos ensues.

"We advise people of normal weight to consume 500-1,000 units of vitamin D a day if they don’t get exposure to the sun, with 2,000 units a day recommended for people with obesity because vitamin D is stored in adipose tissue. The vitamin D we consume is absorbed into adipose tissue and migrates from there to the liver, where it undergoes a process of activation. It then goes to the kidneys, where it undergoes a second activation process. It’s a complex procedure. It’s not a matter of simply taking a dose of vitamin D and problem solved. On the other hand, if the material is stored in adipose tissue, it’s difficult to get rid of because it stays there for three months. That’s why we recommend reasonable doses. What happens is that it’s probably more profitable for pharmacies to sell preparations with higher levels of concentration, and then if you switch from taking five drops of 200 units per drop to a bottle in which every drop is 400 units, you’ve doubled the dose. And that’s not to mention the fact that concentration levels can reach 1,000 units per drop. And that is not advisable."

What about exposure to the sun?

"That’s the simplest. I had a patient who lost her bowel as a result of a combination of pills and smoking. This is a rare case that caused a deficiency in vitamin D. So we said to her: Sit on your balcony for 15 minutes three times a week, during the dangerous hours, and that’s how she boosted her vitamin D levels. She’s a young woman with fair skin, and I should point out that it gets more complicated with age because the body’s capacity to produce vitamin D decreases by 50 percent in our later years and older people struggle to spend time in the sun, certainly here in Israel. Moreover, some people were over-exposed to the sun in their youth and their skin has undergone pre-cancerous changes of various kinds, so sunshine for them is not advisable. To be on the safe side, the elderly should be given a supplement."

What about the ultra-Orthodox, among whom there’s a significant vitamin D deficiency, due in part to the fact that they don’t expose their skin to the sun? Is anything being done to spread the word in this sector?

"I got in touch at some point with one of the rabbis and we organized a seminar on the subject for women in Haifa. I also did some work through Emunah, a religious organization, and tried to promote the whole vitamin D issue. I don’t know how successful I was. A deficiency among women in the ultra-Orthodox population is certainly likely because they don’t get exposure to the sun and are always covered. No one talks to them about the need to take vitamin D. These messages need to be relayed by people within the community, their independent health advisors, and not necessarily the medical establishment."

As a side note, it should be added that lack of exposure to the sun is not the only cause of a vitamin D deficiency. Prof. Troen offers another explanation for the widespread phenomenon, especially among the ultra-Orthodox and Arabs. "We were made privy at some stage to all the results of vitamin D tests conducted over a three-year period by the Leumit, Meuhedet and Maccabi HMOs [Clalit refused to participate]," he relates. "When we studied the data, we found that 80 percent of the tests indicated a deficiency, with the socioeconomic status of the subjects clearly an influencing factor."

In other words, poorer populations with poorer diets, like the Arabs and ultra-Orthodox, suffer from higher rates of deficiency.

What happens is that it’s probably more profitable for pharmacies to sell preparations with higher levels of concentration, and then if you switch from taking five drops of 200 units per drop to a bottle in which every drop is 400 units, you’ve doubled the dose. And that’s not to mention the fact that concentration levels can reach 1,000 units per drop. And that is not advisable.

Confusion reigns also when it comes to the various brands on offer on the shelves and various display stands which promote the supplements. "It’s like with shoes," says Ish-Shalom. "You can buy a regular shoe that’s not necessarily a brand name, and you can buy expensive shoes. Pharmacists need to provide their customers with information about the drops they’re buying; tests we’ve carried out have shown that drops that cost 10 shekels are absorbed just as well as the more expensive supplements."

The next step, says Ish-Shalom, involves research into adding vitamin D to the foods we consume, thereby bringing the supplement into our kitchens. "A study conducted at the Technion - Israel Institute of Technology looked into the possibility of enriching food with a vitamin D additive," she says. "We tested stability and absorption, and the supplement was absorbed perfectly even when encased in protein. Now, the Health Ministry and organizations that deal with sustainability are talking about vitamin D supplements to enrich foodstuffs and dairy products - particularly because our cows don’t wander around in the fields but are kept in cowsheds with roofs and don’t produce vitamin D. The additive form proposed in the study is tasty; the yogurts we made absorbed the vitamin D supplement wonderfully well. But here, too, we need to be careful: What about people who like to eat five yogurts? They could be consuming too much vitamin D."

An interesting point of emphasis that emerges from the National Coronavirus Information Center report concerns the role of magnesium in the activation of vitamin D in the human body. "The researchers also recommend taking magnesium in conjunction with vitamin D in light of the fact that magnesium helps to activate the vitamin, and also because all the enzymes involved in the processing of the vitamin require magnesium," the report says. Ish-Shalom, for her part, says that the vitamin can be activated even without magnesium supplements, but the reference in the report to magnesium is particularly interesting given that a large percentage of the Israel public also suffers from a magnesium deficiency.

Health authorities have been aware of this phenomenon for quite some time too, and it stems from the fact that most of the drinking water in Israel - some 80 percent of household consumption - is desalinated, with the desalination process removing the vital mineral from the seawater. Adding magnesium to drinking water is far from complex, but squabbles over budgets - meager ones, it must be said - have prevented the addition of the mineral to the country’s water for the past 10 years.

Ish-Shalom: "One of the biggest problems in Israel is that the two HMOs use two scales of measurement for vitamin D, which leads to confusion. Someone does a blood test and gets a result but doesn’t pay attention to the unit of measurement. They panic and immediately read an article on the internet in which the information could refer to a different unit of measurement, and chaos ensues."

Prof. Troen says that the list of nutritional deficiencies among Israelis doesn’t end with vitamin D and magnesium, and also includes folic acid, iron, iodine and other minerals and vitamins vital for the health of the public. And according to Troen, although he’s been working on this issue since 1996, it wasn’t until last year that the health minister and the director-general of the ministry upheld recommendations to enrich salt with iodine, flour with iron, folic acid and B12, and milk with calcium and vitamin D. "It’s commonplace around the world to enrich milk with vitamin D, and it’s a tool that’s readily accessible to the public and can be utilized to boost vitamin D absorption and vitamin D levels in the population without changing consumption habits," he says. "Part of the goal of nutritional enrichment is that it isn’t voluntary but mandatory, so that it doesn’t become a marketing tool the likes of which we’re seeing today, with vendors proclaiming: Here, eat this, it’s good for fighting the coronavirus."

A response from the Health Ministry on the issue of magnesium noted that ministry officials are "promoting the matter of correcting magnesium deficiencies in the population through legislation, which will require restoring magnesium to the country’s drinking water. The issue has been under review in recent years, and an advanced pilot program has already been implemented."

In response to a question on public information campaigns concerning the consumption of vitamin D supplements during the coronavirus crisis, the ministry said: "An advisory recommending controlled exposure to the sun or the use of vitamin D supplements has been available online for several months. The announcement states that people are advised to maintain adequate vitamin D levels by going out into the sun bare-armed for a cumulative 20 minutes per day, between 11:00 and 16:00, or by taking a daily supplement of 800-1,000 units of vitamin D, with an emphasis on the elderly and others who don’t get exposure to the sun."

In the coming days, according to the ministry, its Nutrition Division, together with numerous trade unions around the country, will be releasing further clarifications both for adults and for children. "Yes," said the response from the Health Ministry, "the lockdown allows for less exposure to the sun in places that are far from home. You can get a dose of sunshine without going to the beach too, but by simply spending some time outside within the permissible range as dictated by the regulations. When it comes to people in isolation or who are closed up in their homes for an extended period, the use of vitamin D supplements in keeping with the recommended dosage may be advisable."