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Vitamin D and MS: FAQ
FREQUENTLY ASKED QUESTIONS (FAQ)

  1. What is vitamin D3?
  2. Why is vitamin D3 important?

  3. Which symptoms of MS might be alleviated by vitamin D3?
  4. What is the cause of Multiple Sclerosis (MS)?

  5. What does vitamin D deficient mean?
  6. What does vitamin D level mean?

  7. How high is my vitamin D level?
  8. How high should my vitamin D level be?

  9. How do I increase my vitamin D level?
  10. Can I combine sunlight exposure and vitamin D intake to increase my vitamin D level?

  11. How long will it take to increase my vitamin D level?
  12. How do I know if sunlight is strong enough to make vitamin D in my skin?

  13. What is the safe amount of exposure to sunlight?
  14. What to do if the heat of the sun makes my MS symptoms worse?

  15. How much skin should I expose to sunlight?
  16. How long should I stay in the sun?

  17. When should I apply sunscreen?
  18. Does it matter at what time of day I am out in the sun?

  19. Do people with a darker skin need more sun?
  20. Do vitamin D3 levels increase sitting behind a window?

  21. How do I increase my vitamin D level through dietary intake of food?
  22. How much vitamin D3 should I take?

  23. When should I ask my health care provider for a vitamin D blood test?
  24. Do I need to inform my health care provider that I’m taking vitamin D supplements?

  25. What are the side effects of vitamin D3?
  26. Isn’t vitamin D toxic?

  27. Where can I buy vitamin D3 supplements?
  28. What is the difference between vitamin D3 and vitamin D2?

  29. What is the difference between vitamin D3 and 1,25-(OH)2D3?
  30. What does IU stand for?

  31. What does μg or mcg or mug stand for?
  32. What does nmol/L stand for?

  33. What does ng/ml stand for?


  1. What is vitamin D3?

    Vitamin D3, also known as cholecalciferol or colecalciferol, is the substrate (the raw material) for the steroid hormone, 1,25(OH)2D3, also known as calcitriol, involved in many vital functions in most cells of the body. Vitamin D3 is formed in the skin under the influence of UVB in sun- or artificial UVB light. Only a few foods contain some vitamin D3.

  2. Why is vitamin D3 important?

    Vitamin D is required for optimal bone, muscle and nerve health, and appears to have a wide range of other important functions in the body. A low serum vitamin D level may be associated with several (autoimmune) diseases including MS.
    Source: Van der Mei IA. Information on Vitamin D levels for People with Multiple Sclerosis. Menzies Research Institute, 2007.

    Vitamin D is required for optimal bone health, and vitamin D deficiency can lead to osteoporosis and influence neuromuscular function (strength and balance). This can result in falls and ultimately, fractures. Interestingly, recent literature has suggested that vitamin D deficiency might also be associated with the onset of diseases such as multiple sclerosis (MS), diabetes, colorectal cancer, breast cancer, prostate cancer, cardiovascular diseases, periodontal disease and tuberculosis, as well as propensity to falls, chronic pain, all of which indicates that ultraviolet radiation or vitamin D does much more in the body than maintain optimal bone health.
    Source: Van der Mei IA. Information on Vitamin D levels for People with Multiple Sclerosis. Menzies Research Institute, 2007.

  3. Which symptoms of MS might be alleviated by vitamin D3?

    Because sunshine and vitamin D have the potential to dampen an over-active immune system, it is conceivable that sunshine or vitamin D might slow the progression of MS, but this is not proven. The Menzies Research Institute is currently analysing the data of the Longitudinal Study of Multiple Sclerosis in Southern Tasmania to examine this issue.
    Source: Van der Mei IA. Information on Vitamin D levels for People with Multiple Sclerosis. Menzies Research Institute, 2007.

  4. What is the cause of Multiple Sclerosis (MS)?

    Multiple sclerosis (MS) is a neurodegenerative disease of uncertain etiology. In MS, neurodegeneration is thought to be secondary to autoimmune-mediated damage. However, no cohesive explanation yet exists as to how environmental factors interact to induce a neurodegenerative autoimmune response. Insufficient sunlight exposure and chronic viral infections have been proposed as unrelated environmental risk factors for MS. Colleen Hayes and Donald Achaeson suggest that these risk factors may act synergistically to enable the pathogenic autoimmune response. Low ultraviolet light (UVL) exposure depletes vitamin D3 stores, and low vitamin D3 levels correlate strongly with high MS risk. The central nervous system converts vitamin D3 into 1,25-dihydroxyvitamin D3 (1,25-(OH)2D3), a biologically active hormone with antiinflammatory and neuro-protective functions that depend on IL-10-producing regulatory lymphocytes. Herpesvirus infection also correlates with MS risk. Some herpesviruses like Epstein-Barr virus produce an IL-10-like cytokine termed vIL-10. Colleen Hayes and Donald Achaeson hypothesize that vIL-10 may induce a dysfunction of IL-10-producing regulatory lymphocytes, thereby undermining the protective functions of sunlight, vitamin D3, and 1,25-(OH)2D3. The vIL-10 could elicit a host immune response capable of neutralizing or depleting IL-10, or the vIL-10 could compete with IL-10 but fail to perform an essential IL-10 function. In either case, the lack of sunlight exposure and the herpes virus infection might synergize to induce a defect in IL-10-producing regulatory lymphocyte function that undermines self-tolerance mechanisms and enables a pathogenic autoimmune response to neural proteins.
    Source: Hayes CE, Donald Acheson E. A unifying multiple sclerosis etiology linking virus infection, sunlight, and vitamin D, through viral interleukin-10. Med Hypotheses. 2008;71(1):85-90. Epub 2008 Apr 2.

  5. What does vitamin D deficient mean?

    The definition of vitamin D deficient is changing as research is showing that the 25(OH)D concentration in blood for optimal health is higher than were previously thought.

    The cut-off point for vitamin D deficiency is 50 nmol/L, in other words people with a vitamin D level of 50 nmol/L or less are considered vitamin D deficient. People with a vitamin D level above 50 nmol/L are considered vitamin D sufficient. However, controversy exists over what cut-off should be recommended.

    In Tasmania at latitude 41°-43° S, the risk of becoming vitamin D deficient is particularly high in winter and spring. Among people with MS: those more disabled (EDSS > 3) are more often vitamin D deficient all year round and spend less time outside compared to those who are more ambulant. Indeed, the more disabled people with MS were three times more likely to be vitamin D deficient compared to healthy people without MS. There was no difference between the more ambulant people with MS and people without MS. Thus it seems that more disabled people with MS may spend less time outside and therefore have deficient vitamin D levels. Importantly, the more ambulant people with MS were as likely as the healthy people without MS to have vitamin D deficiency, indicating that this is also a concern among the general population.

    Active detection of vitamin D deficiency among people with MS and intervention to restore vitamin D status to adequate levels should be considered as part of the clinical management of MS.
    Source: van der Mei IA, Ponsonby AL, Dwyer T, Blizzard L, Taylor BV, Kilpatrick T, Butzkueven H, McMichael AJ. Vitamin D levels in people with multiple sclerosis and community controls in Tasmania, Australia. J Neurol. 2007 May;254(5):581-90. Epub 2007 Apr 11.

  6. What does vitamin D level mean?

    The vitamin D level is the concentration of 25(OH)D in your blood. The serum 25(OH)D concentration is accepted as the nutritional biomarker of vitamin D sufficiency. Vitamin D levels are higher in summer/autumn, and lower in winter/spring. The vitamin D level reflects both sun exposure and vitamin D intake. It is the marker of vitamin D availability to tissues, including the immune system. Vitamin D levels are lower in people with disability e.g. caused by MS.

  7. How high is my vitamin D level?

    Individuals vary in their vitamin D levels and in their response to efforts to increase these levels.

    A simple blood test can determine your current vitamin D level. To check your vitamin D level, ask your health care provider for a 25(OH)D blood test. Your health care provider can then advise you on whether you need to increase your vitamin D level.
    Source: Van der Mei IA. Information on Vitamin D levels for People with Multiple Sclerosis. Menzies Research Institute, 2007.

  8. How high should my vitamin D level be?

    The recommended minimum vitamin D level is at least 50 nmol/L, but recent research suggests there may be additional benefit in maintaining vitamin D levels of 75, 100 and 125 nmol/L or higher.
    Source: Van der Mei IA. Information on Vitamin D levels for People with Multiple Sclerosis. Menzies Research Institute, 2007.

    Or between 100 - 150 nmol/L.
    Source: Scientists' Call to D*Action

    The average 25(OH)D concentration of the confirmed cases of vitamin D toxicity was 535 nmol/L (214 ng/ml).
    Source: Vieth R. Vitamin D toxicity, policy, and science. J Bone Miner Res. 2007 Dec;22 Suppl 2:V64-8. Review.

  9. How do I increase my vitamin D level?

    There are a few ways to increase vitamin D levels. It also depends on where you live.

    In summer

    • Increase exposure to sunlight;

    In winter
    At latitudes greater than 35° where sunlight is not strong enough in winter to make enough vitamin D3 in the skin.

    • Increase the intake of foods containing vitamin D3 or

    • Take vitamin D supplements or

    • Use artificial UVB light.

  10. Can I combine sunlight exposure and vitamin D intake to increase my vitamin D level?

    To achieve an optimal vitamin D level, it is advisable to combine sunlight exposure and vitamin D intake. Here is an example for people with MS who are ambulant or who are disabled.

    The ambulant (low disability) group had no disability or could walk an unlimited distance without rest but not run.

    Table 1.
    Recommendations for Tasmanians with Multiple Sclerosis to prevent vitamin D deficiency.

    RecomTasmania

    Source: Van der Mei IA. Information on Vitamin D levels for People with Multiple Sclerosis. Menzies Research Institute, 2007.

  11. How long will it take to increase my vitamin D level?

    Since the half-life of 25(OH)D in the circulation is quite long (190), results of treatment may only be assessed after 3 to 6 months or more when a plateau is reached (56) For example taking vitamin D3 400 IU/d or 800 IU/d resulted in an increase mean serum 25(OH)D from 24 nmol/L to 60 or 70 nmol/L, respectively, after 3 months. The increase in serum 25(OH)D also depends on baseline serum 25(OH)D.
    Source: Lips P. Vitamin D deficiency and secondary hyperparathyroidism in the elderly: consequences for bone loss and fractures and therapeutic implications. Endocr Rev. 2001 Aug;22(4):477-501.

    On average it takes sunlight 2 months to optimise vitamin D levels after winter to summer levels.
    Source: VanAmerongen BM, Dijkstra CD, Lips P, Polman CH. Multiple sclerosis and vitamin D: an update. Eur J Clin Nutr. 2004 Aug;58(8):1095-109.

    To optimize vitamin D levels to more than 100 nmol/L depends on on baseline serum 25(OH)D, exposure to sunshine and your vitamin D3 intake. Therefore it is advisable to monitor your vitamin D level. Choice of a larger dose may be based on the wintertime serum 25(OH)D level.

  12. How do I know if sunlight is strong enough to make vitamin D in my skin?

    • When you stand in the sun and you cast a shorter shadow or

    • Use a website that can calculate how long you need to sit in the sun:

    Duration of Vitamin D Synthesis in Human Skin (accessed May 2008).

    • Use a UVB meter Solarmeter

  13. What is the safe amount of exposure to sunlight?

    Exposure to the sun is the cheapest way to increase vitamin D levels, but could come at a cost because it increases the risk of skin cancer and eye disease.
    Source: Van der Mei IA. Information on Vitamin D levels for People with Multiple Sclerosis. Menzies Research Institute, 2007.

    3 hours of sun exposure per week, divided up over at least 2 days. The frequency of sun exposure is important, because your skin stops making vitamin D after about half an hour in the sun.

    Please, take into account the WHO sun protection recommendations for skin cancer prevention (accessed May 2008).

    Table 2.
    WHO sun protection recommendations for skin cancer prevention.4

    RecomWHO

  14. What to do if the heat of the sun makes my MS symptoms worse?

    The heat of the sun might make your MS symptoms worse. If so, don’t stay out in the direct sun for more than 10-15 minutes, or try to avoid the direct heat of the sun by only going outside when there is a pleasant breeze. Alternatively sit in the shade of a tree for 20-30 minutes.

  15. How much skin should I expose to sunlight?

    Expose as much skin as possible. Vitamin D is produced in the body when the skin is exposed to sunlight. Therefore, wearing a lot of clothing, like we do in winter, will limit the amount of vitamin D we produce.

  16. How long should I stay in the sun?

    Avoid excessive sun exposure at all times, including getting sunburnt, as this is a known risk factor for skin cancer, especially melanoma. The risk of sunburn is highest in summer.
    Please, take into account the WHO sun protection recommendations for skin cancer prevention (accessed May 2008).
    Short exposures 10-15 minutes may be more efficient at producing vitamin D3 as continued exposure to UVB results in degradation of vitamin D3.

  17. When should I apply sunscreen?

    Apply sunscreen after 10-15 minutes of skin exposure.

  18. Does it matter at what time of day I am out in the sun?

    The amount of vitamin D3 produced under the influence of the sun depends on the strength of the sun. The strength of the sun varies throughout the year (highest in summer and lowest in winter). It also varies during the day (lower in the morning and late afternoon, higher during the middle of the day). There is a certain threshold below which the body cannot produce any vitamin D3. In Tasmania, people are still able to generate some vitamin D3 in winter but it is less than in summer. Also, being outside early in the morning or late in the afternoon during the winter has little effect on your vitamin D levels.

  19. Do people with a darker skin need more sun?

    People with darker skin require more sun to produce the same amount of vitamin D3 compared to people with lighter skin.

  20. Do vitamin D3 levels increase sitting behind a window?

    Glass filters nearly all ultraviolet radiation rays that are required to produce vitamin D3 in the skin. Therefore, vitamin D levels do not increase if sitting behind a window.

  21. How do I increase my vitamin D level through dietary intake of food?

    Less than 5% of the vitamin D in our body comes from dietary sources. The best source is fatty fish, such as mackerel, herring and wild salmon. Liver, eggs and fortified foods, such as margarine (3 IU/g (0,075 μg/g)) and some milk, also contain a very small amount of vitamin D3. For most people, unless you are an Eskimo eating cod liver oil and fish, adequate vitamin D levels are unlikely to be achieved through diet alone.

  22. How much vitamin D3 should I take??

    Recent studies suggest that the current RDA/DV of vitamin D - 200 IU (5 μg) for individuals under age 50, 400 IU (10 μg) for those between the ages of 50 and 70, and 600 IU (15 μg) for those over the age of 70 - may not be adequate.

    Vitamin D level
    Vitamin D sufficiency is currently defined as a blood test level above 50 nmol/L. However, the optimal vitamin D level is unknown and threshold values of 75 nmol/L, 100 nmol/L or 125 nml/L have been suggested.

    Vitamin D intake
    Take a vitamin D supplement of at least 1000 IU (25 μg) per day. There is general consensus among scientists that vitamin D intake required to prevent vitamin D levels below 50 nmol/L should be at least 1000 IU (25 μg) per day.2 This intake is also recommended by the Canadian Cancer Society. Taking 1000 IU (25 μg) per day seems to increase vitamin D levels on average to about 70 nmol/L.

  23. Some people require more vitamin D3 than others to reach a given level of vitamin D in their blood,
  24. The level of vitamin D in the blood also depends on the amount of exposure to the sun,
  25. The required vitamin D3 intake depends on how high your level is to start with,
    People with MS: Disability was strongly associated with lower vitamin D levels and with less sun exposure.
    Source: Van der Mei IA. Information on Vitamin D levels for People with Multiple Sclerosis. Menzies Research Institute, 2007.


    Vitamin D blood test (25-hydroxyvitamin D or 25(OH)D)
    Your health care provider can request a blood test to have your vitamin D level assessed and can assist you in your treatment:
    • If your vitamin D level is deficient, the treatment has to be aimed at repleting your vitamin D level to above 50 nmol/L.
    • If your vitamin D level is sufficient, the treatment has to be aimed at maintaining that vitamin D level all year round.

    Oral vitamin D supplementation
    Recommendations for treatment of vitamin D deficiency

    • 3000-5000 IU (75 μg – 125 μg) vitamin D3 (cholecalciferol) per day (3-5 capsules of 1000 IU (25 μg) vitamin D3 (cholecalciferol) per day) for 6-12 weeks, after which e.g. 1000 IU per day can be used or
    • 50 000 IU (1.25 mg) vitamin D3 (cholecalciferol) per month (1 capsule of 50 000 IU (1.25 mg) vitamin D3 (cholecalciferol) per month) for 3-6 months, after which e.g. 1000 IU per day can be used or
    • a single dose of up to 500 000 IU (12.5 mg) vitamin D3 (cholecalciferol) (10 capsules of 50 000 IU (1.25 mg), after which e.g. 1000 IU per day can be used.
    Source: Working Group of the Australian and New Zealand Bone and Mineral Society; Endocrine Society of Australia; Osteoporosis Australia. Vitamin D and adult bone health in Australia and New Zealand: a position statement. Med J Aust 2005;182(6):281-5.
    http://www. osteoporosis.org.au/files/research/Sunexposure_OA_2007.pdf, accessed Nov 2007

    Ask your health care provider to monitor your vitamin D levels twice a year, as long as they are deficient. Preferably at the end of winter when vitamin D levels are at their lowest and at the end of summer when they are at their highest. Continue to monitor twice a year until your level is sufficient (at least 50 nmol/L) in winter. As soon as your vitamin D level is sufficient a supplement with 1000 IU (25 μg or 0,025 mg) vitamin D3 (cholecalciferol) per day can be used.

    Recommendations for maintaining vitamin D sufficiency
    The following vitamin D intake is recommended to maintain your vitamin D level above 50 nmol/L:
    There is general consensus among scientists that vitamin D intake required to prevent vitamin D levels below 50 nmol/L should be at least 1000 IU (25 μg) per day.2
    This intake is also recommended by the Canadian Cancer Society.

    • 1000 IU (25 μg) per day increases vitamin D levels on average to about 70 nmol/L.
    • 2000 IU (50 μg) per day increases vitamin D levels on average to about 90 nmol/L.
    • 4000 IU (100 μg) per day increases vitamin D levels on average to about 100/112 nmol/L.3 vieth
    Source: Dawson-Hughes B, Heaney RP, Holick MF, Lips P, Meunier PJ, Vieth R. Estimates of optimal vitamin D status. Osteoporos Int 2005;16(7):713-6.

    Ask your health care provider to monitor your vitamin D levels once a year: at the end of winter when it is at its lowest level. Ajust your doses until your level is at the desired level.
    No adverse effects have been reported at these doses.
    Source: Vieth R, Chan PC, MacFarlane GD. Efficacy and safety of vitamin D3 intake exceeding the lowest observed adverse effect level. Am J Clin Nutr 2001;73(2):288-94.

  26. When should I ask my health care provider for a vitamin D blood test?

    The risk of being vitamin D deficient is generally higher when living further away from the equator and lower when living closer to the equator because of differences in strength of the sun. However, behaviour such as the amount of time spent outside, the time of day being outside, the amount of clothing worn and the use of sunscreen are also important determinants of your level of vitamin D. A blood test, performed by your health care provider, is the best method to determine whether there is a need to increase your vitamin D levels.

  27. Do I need to inform my health care provider that I’m taking vitamin D supplements?

    If you decide to take more than 2000 IU (50 μg) vitamin D supplements per day, it is suggested that you inform your health professional.

  28. What are the side effects of vitamin D3?

    Excessive intakes of vitamin D are evident by hypercalcaemia, dehydration and tissue calcification.1–3 hypercalcaemia hypercalcuria vieth

  29. Isn’t vitamin D toxic?

    The threshold vitamin D level for vitamin D toxicity has not been established. There is no evidence that toxicity occurs at levels below 600 nmol/L (240 ng/ml) or with daily oral consumption of 250 μg (10 000 IU)/d vitamin D3.

    Vitamin D causes hypercalcemia when the "free" concentration of 1,25(OH)2D is inappropriately high. Adminitration of 1,25(OH)2D may cause coronary and valvular calcification.

    Hyper calcemia is the key criterion for vitamin D toxicity. A measure of an impeding adverse response, capable of detecting modest excess in vitamin D, is hypercalciuria. This can be monitored easily by measuring the ratio of calcium to creatinine in a random morning urine sample. Hypercalciuria has been defined as urine calcium/creatinine >1 mmol/mmol (>0.37 mg/mg).
    Source: Vieth R. Vitamin D toxicity, policy, and science. J Bone Miner Res. 2007 Dec;22 Suppl 2:V64-8. Review.

  30. Where can I buy vitamin D3 supplements?

    Vitamin D comes in two forms; D3 and D2. Buy vitamin D3, since this form works better for most people. If the product doesn’t say D3 on the front label, look for the name “cholecalciferol” in the list of ingredients on the back of the bottle – that’s another name for D3.

    Vitamin D3 supplements currently available in

    AUSTRALIA
    There are three over-the-counter pure vitamin D preparations available in Australia, OsteVit-D, Ostelin Vitamin D and Blackmores vitamin D3. Each capsule contains 1000 international units (IU). OsteVit-D and Blackmores both contain vitamin D3 (cholecalciferol). Ostelin contains vitamin D2 (ergocalciferol). People do not produce vitamin D2 naturally in the body and vitamin D2 seems a little less effective in raising vitamin D levels than vitamin D3. OsteVit-D is the least expensive, retailing for around $32 for 250 capsules. Alternatively, a high dose preparation of vitamin D3 (50,000 IU per capsule, taken monthly, around $60 for 12 capsules) can be ordered at Chemist Warehouse (144 Murray St, Hobart) with a prescription from a specialist physician, geriatrician, endocrinologist or rheumatologist.

    - Netherlands
    Vitamine D KIND - Kruidvat
    Devaron® (zelfzorg) Tablet: 400 IE colecalciferol (vitamine D3)
    http://www.consumed.nl/medicijnen/774/Devaron%C2%AE_zelfzorg
    Niet gebruiken bij (= contra-indicaties) o.a.
    o Calcium-gehalte van het bloed, verhoogd (= hypercalciëmie)
    o Nierstenen (tenzij de arts anders voorschrijft)

    Colecalciferol (recept)

  31. What is the difference between vitamin D3 and vitamin D2?

    • Cholecalciferol (vitamin D3), formed in the skin through the action of ultraviolet (UV) light on 7-dehydrocholesterol to produce cholecalciferol. • Ergocalciferol (vitamin D2), produced by UV irradiation of the plant steroid ergosterol.

  32. What is the difference between vitamin D3 and 1,25-(OH)2D3?

    Serum 1,25(OH)2D3 levels play no roll in diagnosing vitamin D deficiency. Serum 1,25(OH)2D3 levels are tightly controlled. They are often normal or even elevated in vitamin D deficiency. Therefore, a patient with normal or high 1,25(OH)2D3 serum levels but low 25(OH)D levels is vitamin D deficient despite high serum levels of the active hormone. Calcitriol (1,25-(OH)2D3) is not appropriate for treating patients with deprivational vitamin D deficiency as it has a narrow therapeutic window, may result in hypercalcaemia or hypercalciuria and does not increase serum 25-OHD levels.

  33. What does IU stand for?

    International Units (IU) 1000 IU equals 0.025 mg or 25 microgram (μg or mcg or mug). In the new official units for vitamins, 1000 IU/d translates to 25 ug/day

  34. What does μg or mcg or mug stand for?

    1 microgram (μg or mcg or mug) equals 40 International Units (IU).

  35. What does nmol/L stand for?

    Vitamin D levels are reported in either ng/mL or nmol/L.
    1.0 nmol/L equals 0.4 ng/mL.

  36. What does ng/ml stand for?

    Vitamin D levels are reported in either ng/mL or nmol/L.
    1.0 ng/mL equals 2.5 nmol/L.