Benefits of Vitamin-D

1. Benefits of Vitamin-D And How does this tie into Chiropractic?

2. What is Vitamin-D? • Vitamin D is a steroid vitamin, a group of fat-soluble prohormones, which encourages the absorption and metabolism of calcium and phosphorous. • Five forms of vitamin D have been discovered, vitamin D1, D2, D3, D4, D5. The two forms usable in humans are vitamins D2 (ergocalciferol) and D3 (cholecalciferol). • Of the two useful forms, D3 is far more bioavailable in the human body than D2, as cholecalciferol is the natural source obtained from the sun, and ergocalciferol is a synthetically produced form that has minimal uptake into the human body.

3. Why Do I Need Vitamin-D? • Crucial for the absorption and metabolism of calcium and phosphorous, for maintenance of healthy bones. • Supports Immune System • Reduced risk of developing Multiple Sclerosis • Enhance brain function, particularly long-term • Anti-inflammatory/Relief from chronic musculoskeletal pain. Reduced severity, frequency, and hospitalizations from asthma • Reduced risk of Rheumatoid Arthritis, particularly in women. • Protection from cellular damage due to radiation. • Reduce the risk of cancer • Reduced risk of heart attack ,cardiovascular events, and high Blood pressure. • Protection from various birth complications

4. Bone Support • Osteoporosis is most often associated with inadequate calcium intake. However, a deficiency of vitamin D also contributes to osteoporosis by reducing calcium absorption.33 While rickets and osteomalacia are extreme examples of vitamin D deficiency, osteopororsis is an example of a long-term effect of vitamin D insufficiency.34 Adequate storage levels of vitamin D help keep bones strong and may help prevent osteoporosis in older adults, in those who have difficulty walking and exercising, in post-menopausal women, and in individuals on chronic steroid therapy.35 • Vitamin D deficiency, which is often seen in post-menopausal women and older Americans, has been associated with greater incidence of hip fractures.39-41 In a review of women with osteoporosis hospitalized for hip fractures, 50 percent were found to have signs of vitamin D deficiency.35 Daily supplementation with 800 IU of vitamin D may reduce the risk of osteoporotic fractures in elderly populations with low blood levels of vitamin D.42 The Decalyos II study examined the effect of combined calcium and vitamin D supplementation in a group of elderly women who were able to walk indoors with a cane or walker. The women were studied for two years, and results suggested that such supplementation could reduce the risk of hip fractures in this population.43

5. Immune Support • Important way to arm the immune system against disorders like the common cold, report investigators from the University of Colorado Denver (UC Denver) School of Medicine, Massachusetts General Hospital (MGH) and Children's Hospital Boston. People with the lowest blood vitamin D levels reported having significantly more recent colds or cases of the flu. The risks were even higher for those with chronic respiratory disorders, such as asthma and emphysema. • Recent years evidence has accumulated that vitamin D may also play a key role in the immune system. Circumstantial evidence has implicated the wintertime deficiency of vitamin D, which the body produces in response to sunlight, in the seasonal increase in colds and flu; and small studies have suggested an association between low blood levels of vitamin D and a higher risk of respiratory infections. • Multiple sclerosis (MS) results from a failure of the body to recognize itself. The immune system attacks and destroys the sheath that protects nerve fibers, as if it were a foreign body or infection. Vitamin-D is an immune system regulator, which is may contribute to the fact that MS is less common in sunnier countries. Giving MS sufferers Vitamin- D pills - or encouraging them to spend more time in the sun - might be a cheap and easy treatment. Oral vitamin D therapy is now in phase II clinical trials, to see how well it works and how much would be needed. • Studies show that individuals, particularly women, with the highest levels of Vitamin-D are 30% less likely to develop rheumatoid arthritis than women with the lowest levels of Vitamin- D. There was a direct link between dietary and supplemental vitamin D intake and a reduced risk of rheumatoid Dietary intake reduced the risk by 28% while supplemental intake reduced risk by 34%.Researchers found that supplemental intake reduced rheumatoid arthritis risk significantly. They found no single food which was strongly linked to rheumatoid arthritis risk. They did find, however, that those who consumed the most milk has a lower risk of developing rheumatoid arthritis. • Serum levels of vitamin D in more than 600 Costa Rican children were inversely linked to several indicators of allergy and asthma severity, including hospitalizations for asthma, use of inhaled steroids and total IgE levels.It was found that children with lower vitamin D levels were significantly more likely to have been hospitalized for asthma in the previous year, tended to have airways with increased hyperreactivity and were likely to have used more inhaled corticosteroids, all signifying higher asthma severity. These children were also significantly more likely to have several markers of allergy, including dust-mite sensitivity.

6. Anti-inflammatory/Pain Relief • Those with non-traumatic, persistent musculoskeletal pain often display overt vitamin-D deficiency. • Studies have shown that supplementation with 5,000 IU/d of vitamin-D has been shown to reduce pain in 100% of subjects within 3 months.

7. Reduced risk of Cancer • Laboratory, animal, and some preliminary human studies suggests that vitamin D may be protective against some cancers. Several studies suggest that a higher dietary intake of calcium and vitamin D correlates with lower incidence of cancer, and that greater sun exposure reduces cancer deaths.44-51 The inverse relationship between higher vitamin D levels in blood and lower cancer risk in humans is best documented for colon and colorectal cancers.44-50 Vitamin D emerged as a protective factor in a study of over 3,000 adults who underwent a colonoscopy to look for polyps or lesions in the colon. There was a significantly lower risk of advanced cancerous lesions among those with the highest vitamin D intake.52 • Vitamin D deficiency was found to be prevalent in cancer patients regardless of nutritional status, according to the results of a recent study conducted at Cancer Treatment Centers of America (CTCA). Based on these results, CTCA researchers determined that screening for vitamin D deficiency and aggressive vitamin D repletion should be considered for all people with cancer."While emerging evidence suggests the protective role of vitamin D in cancer, vitamin D status is not routinely assessed in cancer patients despite the high prevalence of malnutrition in this population," said Carolyn Lammersfeld, national director of nutrition for CTCA and a principal investigator in the study.During the study, a consecutive case series of 737 cancer patients (302 male and 435 female) seen at CTCA between January - June 2008, were assessed for nutritional status and categorizes into three distinct classes of nutritional status: well nourished, moderately malnourished and severely malnourished. The mean age at presentation was 55.7 years (SD = 10.2) and the most common cancer types were lung (133, 18%), breast (131, 17.8%), colorectal (97, 13.2%), pancreatic (86, 11.7%), prostate (44, 6%) and ovarian (38, 5.2%).Before the study, the researchers hypothesized that malnutrition could contribute to vitamin D deficiency and therefore expected mean serum 25-hydroxy-vitamin D [25(OH)D] levels to be significantly lower in malnourished oncology patients. However contrary to what they expected, vitamin D deficiency was found to be prevalent in cancer regardless of nutritional status.

8. Long-Term Brain Support • Vitamin-D may have a key role in helping the brain to keep working well in later life, suggests research published in the Journal of Neurology Neurosurgery and Psychiatry. Research in subjects in the age range of 40-79 indicates that inadequate Vitamin-D intake may be linked to poorer mental agility in the aging brainHigh circulating vitamin D levels were associated with high scores on the memory and information processing tests, but after adjusting for mood and physical activity, the association remained for only one of the two information processing tests. Low vitamin D levels were associated with poor scores, with levels of 35 nmol/litre or under marking the threshold of poorer performance. Possible suggestions include vitamin D's role in increasing certain hormonal activity or the protection of neurons and chemical signaling pathways.

9. Reduced Risk for Cardiovascular Pathology and High Blood Pressure • The results of epidemiological and clinical studies suggest an inverse relationship between serum vitamin D levels and blood pressure. Data from epidemiological studies suggest that conditions that decrease vitamin D synthesis in the skin, such as having dark skin and living in temperate latitudes, are associated with increased prevalence of hypertension.71 In randomized controlled trials of vitamin D supplementation, a combination of 1,600 IU/day of vitamin D and 800 mg/day of calcium for eight weeks significantly decreased systolic blood pressure in elderly women by 9% compared to calcium alone,73 but supplementation with 400 IU/day or a single dose of 100,000 IU of vitamin D did not significantly lower blood pressure in elderly men and women over the next two months.74, 75 At present, data from controlled clinical trials are too limited to determine whether vitamin D supplementation will be effective in lowering blood pressure or preventing hypertension. • various population studies have demonstrated that low levels of this Vitamin-D may increase the risk of developing ischemic heart disease, angina, coronary arteriosclerosis, and heart attack.Other research has suggested that low levels of this vitamin may cause high blood pressure, which increases the risk of heart attack. Results showed that low Vitamin D levels compared to optimal levels are linked to: 64% higher risk of heart attack 57% higher risk of early death 40% higher risk of ischemic heart disease at least 81% higher risk of death from heart diseaseAfter controlling for certain variables that could impact the results, the higher risks were still evident.

10. Protection from Birth Complications • Women with circulating 25-hydroxyvitamin D [25(OH)D] level less than 50 nmol/l in pregnancy experienced an increased risk of preeclampsia [OR 2.09 (95%CI 1.50 -2.90)], gestational diabetes mellitus [OR1.38 (1.12-1.70)], preterm birth [OR1.58 (1.08-2.31)] and small-for-gestational age [OR 1.52 (1.08-2.15)]. • Low maternal vitamin D levels in pregnancy may be associated with an increased risk of preeclampsia, gestational diabetes mellitus, preterm birth and small-for-gestational age. • Supplementation with 4000 IU/day was associated with lower risk of hypovitaminosis D than Control and 2000 IU groups. While not statistically significant, there was a trend toward lower rates of COP as supplementation dose increased. Maternal delivery 25(OH)D was inversely associated with any comorbidity of pregnancy, with fewer events as 25(OH)D increased.

11. Where can I get Vitamin-D? Vitamin D2, ergocalciferol (made from ergosterol). Produced by invertebrates (animals without a spine, vertebral column), fungus and plants in response to sunlight (UV irradiation). Humans and other vertebrates do not produce vitamin D2. Ergosterol is a good absorber of ultraviolet radiation which can damage DNA, RNA and protein; consequently many scientists believe it may serve as a sunscreen that protects organisms from sunlight damage. This form has been synthesized and added to dietary-fortified foods such as milk, cereals, and breads. Vitamin D3, cholecalciferol (made from 7-dehydrocholesterol). Vitamin D3 is made in the skin when 7-dehydrocholesterol reacts with ultraviolet light when the UV index is greater than 3. A UV index of more than 3 occurs every day in the tropics, every day during some of spring, all of summer, and parts of autumn in temperate areas, and hardly ever at all in the arctic circles. The number of days of the year when the UV index is greater than 3 become fewer the further you move away from the tropics. A human requires ten to fifteen minutes of sun exposure at least twice a week on the face, arms, hands, or back without sunscreen with a greater than 3 UV index for adequate amounts of vitamin D3.

12. Where Can I Get Vitamin-D? • If your body cannot produce enough vitamin D because of insufficient sunlight exposure, dark skin, or due to reduced conversion in the elderly, you will need to obtain it from foods and perhaps supplements. • Not that many foods contain vitamin D. Some fish, such as salmon, tuna and mackerel, as well as fish liver oils are considered to be the best sources. Some vitamin D is also present in beef liver, cheese and egg yolks. Most of these are Vitamin D3. Some mushrooms and fortified foods such as bread and cereals provide variable amounts of vitamin D2.Most of the food sourced vitamin D in the western diet comes from fortified foods - where vitamin D is artificially added- examples include breakfast cereals, bread, pastries, oil spreads, margarine, milk and other dairy products.

13. How does Vitamin-D Get Used in My Body?

14. Vitamin-D’s Helpers • Calcium, when combined in the proper ratios with Vitamin-D and magnesium, further accentuates the numerous benefits of Vitamin-D that were previously discussed, particularly bone health, heart and blood vessel health, and lowered blood pressure. • Calcium can be found in five sources, with the most beneficial source being calcium citrate. • The absorption and metabolism of calcium and magnesium is one of mutual dependence, and therefore, the balance between these two minerals is especially important.  If calcium consumption is high, magnesium intake needs to be high also. • The ideal ratio for most people's needs is a 1:1 ratio of calcium and magnesium, both of which should be taken at 2,000 mg/d. • Magnesium raises blood levels of calcium, potassium and vitamin D. • Magnesium is required both for calcium to be absorbed in the intestinal tract, and to help calcium dissolve into solution in the bloodstream.  • Vitamin D requires magnesium in order to convert into its active form in the bloodstream.  Therefore, vitamin D 'uses up' magnesium, which can actually create overt deficiency symptoms quite rapidly. • Magnesium malate and glycinate have been found to be the most effective supplemental forms. • Supplement with vitamin K2, which is found primarily in fermented foods, butter, and animal fats. • The optimal amounts of vitamin K2 are still under investigation, but current recommendations are 100 mcg of vitamin K2 for every 1,000 units of vitamin D. • Vitamin K2 ensures proper calcium transportation and deposition. Taking vitamin D, creates an increased demand for K2, and vitamin D and K2 work together to strengthen your bones and improve your heart health.

15. How Much Do I need? • Data collected from the National Health and Nutrition Examination Survey (NHANES), USA found that 9% (7.6 million) of children across the USA were vitamin D deficient (defined as less than 15 ng/mL of blood), while another 61 percent, or 50.8 million, were vitamin D insufficient (15 to 29 ng/mL) . "We expected the prevalence of vitamin D deficiency would be high, but the magnitude of the problem nationwide was shocking," says lead author Juhi Kumar, M.D., M.P.H., a fellow in pediatrics at Children's Hospital at Montefiore Medical Center, The University Hospital and Academic Medical Center for Albert Einstein College of Medicine. • According to the Food Nutrition Board at the Institute of Medicine of The National Academies, people should take the following amounts of vitamin D if nothing is being synthesized (no sunlight exposure): Children up to 13 years - 5 mcg (200 IU) 14-18 years - 5 mcg (200 IU) 19-50 years - 5mcg (200 IU) 51-70 years - 10 mcg (400 IU) 71+ years - 15 mcg (600 IU) • The American Academy of Pediatrics recommends that exclusively or partially breastfed babies should receive supplements of 400 IU per day shortly after birth. • Weaned babies should consume a minimum of 1,000 mL/day of vitamin D fortified formula or whole milk. Non-breastfed infants consuming less than 1,000 mL/day of vitamin D-fortified formula or milk should receive a vitamin D supplement of 400 IU per day. • Older children and adolescents who do not get 400 IU per day through vitamin D fortified milk and foods should take a 400 IU vitamin supplement each day.

16. How Much Do I Need? • Many experts recommend much higher doses, up to 2,000-4,000 IU/day. • 2 major studies showed convincing evidence that an increased intake of calcium and vitamin D reduces the risk of cancer.  The first of these studies was a 10 year study that associated a lower risk of developing pre menopausal breast cancer with women that consumed a diet high in calcium and vitamin D2 • The second, released in the American Journal of Clinical Nutrition, concludes that a higher intake of vitamin D and calcium reduces the risk of developing cancer.   This 4 year study involved women supplementing 1,500 mg of calcium and 1,100 IU of vitamin D daily compared to a group of women taking a placebo pill as a control. • Further research has suggested that the RDI for vitamin D could be raised to 10,000 IU without raising concerns of vitamin D toxicity.

17. Can I Get Too Much of a Good Thing? • It is very rare to have a vitamin D overdose. However, the primary sign of Vitamin D toxicity involves hypercalcemia, which could result in the following if untreated over a prolonged period of time: bone loss kidney stones calcification of organs like the heart and kidneys • Due to the severe consequences of hypercalcemia, the Food and Nutrition Board established a very conservative UL of 2,000 IU/day (50 mcg/day) for children and adults.28 • Research suggests that the UL for adults is overly conservative • Vitamin D toxicity is very unlikely in healthy people at intake levels lower than 10,000 IU/day.36, 76, 77 Vitamin D toxicity has not been observed to result from sun exposure. • Certain medical conditions can increase the risk of hypercalcemia in response to vitamin D : primary hyperparathyroidism Sarcoidosis: inflamed lymph nodes, lungs, liver, eyes, skin, or other tissues. Tuberculosis: contagious bacterial infection. involves lungs, but may spread. Lymphoma: cancer that begins in immune system cells called lymphocytes.

18. Are There Any Reasons To Avoid Taking Vitamin-D? • Vitamin-D is very safe and has no known negative side effects when taken within the previously discussed ranges. • However, a few precautions should be noted when increasing one’s levels of Vitamin-D: The following medications increase the metabolism of vitamin D and may decrease serum D levels: Phenytoin (Dilantin), fosphenytoin (Cerebyx), phenobarbital (Luminal), carbamazepine (Tegretol), and rifampin (Rimactane). The following medications should not be taken at the same time as vitamin D because they can decrease the intestinal absorption of vitamin D: Cholestyramine (Questran), colestipol (Colestid), orlistat (Xenical), mineral oil, and the fat substitute Olestra. The oral anti-fungal medication ketoconazole. • The induction of hypercalcemia by toxic levels of vitamin D may precipitate cardiac arrhythmia in patients on digitalis (Digoxin).78, 79

19. How Does This Relate to Chiropractic? • Chiropractic care is wholistic, seeking to improve the well-being of the entire body through manual techniques such as adjustments and soft tissue care, as well as helping to educate patients in making the best lifestyle choices through nutrition, supplementation, and exercise habits. • The nervous system innervates and controls the functions of the entire body, both the internal visceral systems, as well as the external musculo-skeletal system. • Chiropractic adjustments to correct vertebral subluxations have been shown to be helpful for many of the same conditions as Vitamin-D- weakened immune system, inflammation/ musculo-skeletal pain, Heart Attacks, High Blood Pressure, RA, and Pregnancy complications.

20. References • 1.  Heaney RP. Long-latency deficiency disease: insights from calcium and vitamin D. Am J ClinNutr 2003;78:912-9 • 2.  Parfitt AM. Osteomalacia and related disorders. In: Avioli LV, Krane SM, etc. Metabolic bone disease and clinically related disorders. 2nd ed. Philadelphia: WB Saunders. 1990:329-96 • 3.  LeBoff MS, Kohlmeier L, Hurwitz S, Franklin J, Wright J, Glowacki J. Occult vitamin D deficiency in postmenopausal US women with acute hip fracture. J Am Med Assoc 1999;251:1505-11 • 4.  Menopausal Hormone Therapy: Summary of a Scientific Workshop. Annals of Internal Medicine 2003;138:361-4. • 5.  Chapuy MC Arlot ME, Duboeuf F, Brun J, Crouzet B, Arnaud S, Delmas PD, Meunier PJ. Vitamin D3 and calcium to prevent hip fractures in elderly women. N Engl J Med 1992;327:1637-42. • 6.  Dawson-Hughes B, Harris SS, Krall EA, Dallal GE, Falconer G, Green CL. Rates of bone loss in postmenopausal women randomly assigned to one of two dosages of vitamin D. Am J ClinNutr 1995;61:1140-45. • 7.  Rodriguez-Martinez MA and Garcia-Cohen EC. Role of Ca2+and vitamin D in the prevention and treatment of osteoporosis. Pharmacology & Therapeutics 2002;93:37-49. • 8.  Reid IR. Therapy of osteoporosis: Calcium, vitamin D, and exercise. Am J Med Sci 1996;312:278-86. • 9.  Chapuy MC, Pamphile R, Paris E, Kempf C, Schlichting M, Arnaud S, Garnere P, Meunier PJ. Combined calcium and vitamin D3 supplementation in elderly women: confirmation of reversal of secondary hyperparathyroidism and hip fracture risk: the Decalyos II study. Osteoporosis Int 2002;13:257-264. • 10. (2009, February 24). "Risk Of Colds And Flu May Be Increased By Vitamin D Deficiency." Medical News Today. • 11. Kathleen Wets. (2009, May 28). "Link Between Vitamin D And Reduction In Multiple Sclerosis Risk." Medical News Today. • 12. (2004, January 12). "High vitamin D intake linked to reduced risk of rheumatoid arthritis." Medical News Today. • 13. (2009, April 24). "Vitamin D Levels Linked To Asthma Severity." Medical News Today. • 14. Journal Of Neurology Neurosurgery And Psychiatry. (2009, May 21). "Vitamin D May Have Key Role In Helping Brain Work Well In Later Life." Medical News Today. • 15.  Posner G. Low-Calcemic Vitamin D Analogs (Deltanoids) for Human Cancer Prevention. J. Nutr 2002;132:3802S-3S.

21. References • 16.  Martinez ME and Willett W C. Calcium, vitamin D, and colorectal cancer: a review of the epidemiologic evidence. Cancer Epidemiol. Biomark. Prev 1998;7:163-68. • 17.  Garland C, Shekelle R B, Barrett-Connor E, Criqui MH, Rossof A H and Paul O. Dietary vitamin D and calcium and risk of colorectal cancer: a 19-year prospective study in men. Lancet 1985;1:307-9. • 18.  Holt PR. Studies of calcium in food supplements in humans. Ann N Y AcadSci 1999;889:128-37. • 19.  Langman M and Boyle P. Chemoprevention of colorectal cancer. Gut 1998;43:578-85. • 20.  Glinghammar B, Venturi M, Rowland IR, Rafter JJ. Shift from a dairy product-rich to a dairy product-free diet: Influence on cytotoxicity and genotoxicity of fecal water--potential risk factors for colon cancer. Am J ClinNutr 1997;66:1277-82. • 21.  La Vecchia C, Braga C, Negri E, Franceschi S, Russo A, Conti E, Falcini F, Giacosa A, Montella M, Decarli A. Intake of selected micronutrients and risk of colorectal cancer. Int J Cancer 1997;73:525-30. • 22.  Vieth R. Vitamin D supplementation, 25-hydroxyvitamin D concentrations, and safety. Am J ClinNutr 1999 69 :842-56. • 23.  Lieberman DA, Prindiville S, Weiss DG, Willett W. Risk factors for advanced colonic neoplasia and hyperplastic polyps in asymptomatic individuals. J Am Med Assoc 2003;290:2959-67. • (2012, September 24). "Low Levels of Vitamin D Linked To Heart Disease." Medical News Today. • 24.  Rostand SG. Ultraviolet light may contribute to geographic and racial blood pressure differences. Hypertension. 1997;30(2 Pt 1):150-156. (PubMed) • 25.  Pfeifer M, Begerow B, Minne HW, Nachtigall D, Hansen C. Effects of a short-term vitamin D(3) and calcium supplementation on blood pressure and parathyroid hormone levels in elderly women. J ClinEndocrinolMetab. 2001;86(4):1633-1637. (PubMed) • 26.  Pan WH, Wang CY, Li LA, Kao LS, Yeh SH. No significant effect of calcium and vitamin D supplementation on blood pressure and calcium metabolism in elderly Chinese. Chin J Physiol. 1993;36(2):85-94. (PubMed) • 27.  Scragg R, Khaw KT, Murphy S. Effect of winter oral vitamin D3 supplementation on cardiovascular risk factors in elderly adults. Eur J ClinNutr. 1995;49(9):640-646. (PubMed) • 28.  Vieth R, Chan PC, MacFarlane GD. Efficacy and safety of vitamin D3 intake exceeding the lowest observed adverse effect level. Am J ClinNutr. 2001;73(2):288-294. (PubMed) • 29.  Heaney RP, Davies KM, Chen TC, Holick MF, Barger-Lux MJ. Human serum 25-hydroxycholecalciferol response to extended oral dosing with cholecalciferol. Am J ClinNutr. 2003;77(1):204-210. (PubMed)

22. References • 30.Vitamin D. Natural Medicines Comprehensive Database [Web site]. March 1, 2004. Available at: www.naturaldatabase.com. Accessed March 1, 2004. •  31.  Hendler SS, Rorvik DR, eds. PDR for Nutritional Supplements. Montvale: Medical Economics Company, Inc; 2001. • 32. J Matern Fetal Neonatal Med. 2013 Jan 13. [Epub ahead of print] Maternal Vitamin D Status and Adverse Pregnancy Outcomes: A Systematic Review and Meta-Analysis. Wei SQ, Qi HP, Luo ZP, Fraser WD. • 33. J Steroid Biochem Mol Biol. 2013 Jan 10. pii: S0960-0760(13)00006-X. doi: 10.1016/j.jsbmb.2013.01.002. [Epub ahead of print] Health Characteristics and Outcomes of Two Randomized Vitamin D Supplementation Trials during Pregnancy: A Combined Analysis. Wagner CL, McNeil JB, Johnson DD, Hulsey TC, Ebeling M, Robinson C, Hamilton MH, Hollis BW. • 34.http://www.naturalnews.com/037042_pregnancy_chiropractic_pain_relief.html • 35. Huizinga TW, Pincus T. In the clinic. Rheumatoid arthritis. Ann Intern Med. 2010 Jul 6;153(1). • 36. J Chiropr Med. 2008 September; 7(3): 86–93. Published online 2008 September 2. doi:  10.1016/j.jcm.2008.04.001. Sympathetic and parasympathetic responses to specific diversified adjustments to chiropractic vertebral subluxations of the cervical and thoracic spine. Arlene Welcha, and Ralph Booneb • 37. Parham Erfanian, DC, FCCRS(C). Patient with signs and symptoms of myocardial infarction presenting to a chiropractic office: a case report. JCCA 2001. • 38. Brennan PC, Triano JJ, McGregor M, et al. Enhanced neutrophil respiratory burst as a biological marker for manipulation forces: duration of the effect and association with substance P and tumor necrosis factor. J Manipulative PhysiolTher 1992; 15(2):83 • 39. Plotnikoff GA, Quigley JM. Prevalence of severe hypovitaminosis D in patients with persistent, nonspecificmusculoskeletalpain. Mayo ClinProc. 2003;78(12):1463-70 • 40. Masood H, Narang AP, Bhat IA, Shah GN. Persistent limb pain and raised serum alkaline phosphatase the earliest markers of subclinical hypovitaminosis D in Kashmir. Indian J PhysiolPharmacol. 1989;33(4):259-61. • 41. Al Faraj S, Al Mutairi K. Vitamin D deficiency and chronic low back pain in Saudi Arabia. Spine. 2003;28(2):177-9. • 42. Constantine S. Anast, James M. Mohs, Sheldon L. Kaplan, Thomas W. Burns. Evidence for Parathyroid Failure in Magnesium Deficiency. Science 18 August 1972: Vol. 177 no. 4049 pp. 606-608. • 43. Ariel Rösler, David Rabinowitz. MAGNESIUM-INDUCED REVERSAL OF VITAMIN-D RESISTANCE IN HYPOPARATHYROIDISM. The Lancet. Volume 301, Issue 7807, 14 April 1973, Pages 803–805. • 44. Coudray, C. Rambeau, M. Feillet-Coudray, C. Gueux, E. Tressol, J. C. Mazur, A. Rayssiguier, Y. Study of magnesium bioavailability from ten organic and inorganic Mg salts in Mg-depleted rats using a stable isotope approach. Magnes Res. 2005 Dec; 18 (4): 215-23.