all things vitamin D

Discuss herbal therapies, vitamins and minerals, bee stings, etc. here

Postby jimmylegs » Sun Sep 26, 2010 5:37 pm

Thank you for the opportunity to provide input on proposal 10-HLTC032.

I have copied the proposal text below and have inserted my comments and relevant research citations and quotes throughout, separated by asterisks like so: *****


ONTARIO PROPOSAL: Funding of Vitamin D Testing Based on Clinical Evidence

Ministry: Ministry of Health and Long-Term Care
Regulation Number(s): 552

Bill or Act: Health Insurance Act
Summary of Proposal: The Ministry of Health and Long-term Care (MOHTLC) will be improving the quality and value of health care based on the best medical evidence available by providing Vitamin D testing as an insured service to Ontarians with the following conditions: Osteoporosis, Rickets, Osteopenia, Malabsorption Syndromes and Renal Disease; or
Ontarians who are on medications that affect Vitamin D metabolism. This proposal is aligned with the Excellent Care for All Act that will improve quality, value and promote evidence-based health care. The Act will ensure that future investments get results and improve health while preserving the health care system for future generations.

*****

MY COMMENTS: Vitamin D testing as an insured service must be provided to Multiple Sclerosis patients. Patients must be able to determine whether their dietary and supplementation regimens are successfully achieving levels above 100 nmol/L, without exceeding 250 nmol/L.

Some cases of Vitamin D3 deficiency or insufficiency are refractory and without testing it is impossible to know whether following a regimen is making the required difference in serum levels.

At the upper end of the scale, concerns regarding Vitamin D3 toxicity issues (such as hypercalcaemia) indicate that patients using therapeutic intakes of Vitamin D3 must be monitored.

*****

On the relevance of Vitamin D3 to MS:

STUDY: Serum 25-Hydroxyvitamin D Levels and Risk of Multiple Sclerosis
Kassandra L. Munger, MSc; Lynn I. Levin, PhD, MPH; Bruce W. Hollis, PhD; Noel S. Howard, MD; Alberto Ascherio, MD, DrPH
JAMA. 2006;296:2832-2838.
http://www.ncbi.nlm.nih.gov/pubmed/17179460

"...the highest quintile, corresponding to 25-hydroxyvitamin D levels higher than 99.1 nmol/L..." "The results of our study suggest that high circulating levels of vitamin D are associated with a lower risk of multiple sclerosis."

STUDY: Vitamin D intake and incidence of multiple sclerosis
K. L. Munger, MSc, S. M. Zhang, MD ScD, E. O’Reilly, MSc, M. A. Hernán, MD DrPH, M. J. Olek, DO, W. C. Willett, MD DrPH and A. Ascherio, MD DrPH
NEUROLOGY 2004;62:60-65
http://www.ncbi.nlm.nih.gov/pubmed/14718698

"The pooled age-adjusted relative risk (RR) comparing women in the highest quintile of total vitamin D intake at baseline with those in the lowest was 0.67 (95% CI = 0.40 to 1.12; p for trend = 0.03). Intake of vitamin D from supplements was also inversely associated with risk of MS;"

*****

ONTARIO PROPOSAL: Studies of the general population suggest a relatively low prevalence, approximately 5%, of Canadians had Vitamin D deficiency, and between 10% and 25% had low Vitamin D levels. Since 2005, reports have promoted Vitamin D testing and have contributed to the sharp increase in demand for Vitamin D testing in Ontario. Annual billing data shows that Vitamin D testing volumes increased 2500% from 2004/2005 to 2009/2010. If this trend continues, billings could reach up to $155M by 2011/12, for both medically necessary and unwarranted tests.

*****

MY COMMENTS: I would be interested to see which studies are referred to above. How do these terms line up with the following proposed classification?

*****

STUDY: Secondary hyperparathyroidism in the elderly: means to defining hypovitaminosis D.
McKenna MJ, Freaney R.
Osteoporos Int. 1998;8 Suppl 2:S3-6.
http://www.ncbi.nlm.nih.gov/pubmed/10197175

in

STUDY: Vitamin D deficiency: a neglected aspect of disturbed calcium metabolism in renal failure
Jorge B. Cannata‐Andía and Carlos Gómez Alonso
http://ndt.oxfordjournals.org/content/1 ... ull#ref-16

"The following classification has been proposed:
(i) Hypovitaminosis D: concentrations between 20 and 40 ng/ml (50 and 100 nmol/l).

(ii) Vitamin D insufficiency: plasma concentration between 10 and 20 ng/ml (25-50 nmol/l).

(iii) Vitamin D deficiency: 25(OH)D concentrations <10 ng/ml (25 nmol/l)."

*****

MY COMMENTS: Does the literature review include any studies which suggest that levels below 100 nmol/L may actually indicate deficiency, as opposed to hypovitaminosis D?

*****

STUDY: Lessons for nutritional science from vitamin D.
Heaney RP.
Am J Clin Nutr. 1999 May;69(5):825-6.
http://www.ncbi.nlm.nih.gov/pubmed/10232617

"Vieth makes a point that should help us with the needed mental adjustment: individuals exposed to the sun for much of the year in lower latitudes always have blood 25(OH)D concentrations values >100 nmol/L. So, if the true lower limit of the acceptable normal range is, in fact, 100 nmol/L, it could hardly be considered 'high'."

*****

ONTARIO PROPOSAL: Vitamin D testing is currently insured for all Ontarians under OHIP. However, there is no evidence that routine testing of Vitamin D levels encourages adherence to Health Canada’s guidelines. At present, the most efficient way to ensure adequate Vitamin D levels in healthy individuals is to promote Health Canada’s guidelines for maintaining sufficient levels.

*****

MY COMMENTS: By "no evidence", do you mean that no one has investigated testing and adherence yet? If there is a study on this matter which concludes testing does not affect adherence, I would be pleased to read it if you would be so good as to refer me.

In any case, Health Canada's guidelines are insufficient to guarantee serum levels of vitamin D3 at levels associated with least risk of Multiple Sclerosis.
http://www.hc-sc.gc.ca/fn-an/nutrition/ ... bl-eng.php
Health Canada AI = 200 - 600 IU/d, UL 2000 IU/d

The study cited below shows that on 1000 IU/d, the absolute best a patient can do is get up to the cutoff. Even on 4000 IU per day some patients only achieved serum levels between 69 and 100 nmol/L.

This study also demonstrates the wild variability in patients’ serum levels when supplementing identical levels on a daily basis.

[Personal anecdote: my dose-response to one vitamin D3 regimen (a booster, not a maintenance regimen) resulted first in a serum increase of approx 70 nmol/L, and the next time in a serum increase of approx 170 nmol/L, which put me well over 250 nmol/L, the cutoff above which hypercalcemia may occur. Without testing I would have had no idea.]

Vitamin D3 testing is required to ensure that a patient’s daily regimen is successfully getting their serum level above the cutoff, and in some cases it is required to ensure they remain below the upper end of the safe range.

*****

STUDY: Efficacy and safety of vitamin D3 intake exceeding the lowest observed adverse effect level
Reinhold Vieth, Pak-Cheung R Chan and Gordon D MacFarlane
American Journal of Clinical Nutrition, Vol. 73, No. 2, 288-294, February 2001
http://www.ncbi.nlm.nih.gov/pubmed/11157326

"The minimum and maximum plateau serum 25(OH)D concentrations in subjects taking 25 and 100 microg (1000 and 4000 IU) vitamin D3/d were 40 and 100 nmol/L and 69 and 125 nmol/L, respectively."

STUDY: A phase I/II dose-escalation trial of vitamin D3 and calcium in multiple sclerosis.
Burton JM, Kimball S, Vieth R, Bar-Or A, Dosch HM, Cheung R, Gagne D, D'Souza C, Ursell M, O'Connor P.
Neurology. 2010 Jun 8;74(23):1852-9. Epub 2010 Apr 28.
http://www.ncbi.nlm.nih.gov/pubmed/20427749

"Although there may have been confounding variables in clinical outcomes, treatment group patients appeared to have fewer relapse events and a persistent reduction in T-cell proliferation compared to controls.
CONCLUSIONS: High-dose vitamin D (approximately 10,000 IU/day) in multiple sclerosis is safe, with evidence of immunomodulatory effects."

STUDY: Higher 25-hydroxyvitamin D is associated with lower relapse risk in multiple sclerosis.
Simpson S Jr et al
Ann Neurol. 2010 Aug;68(2):193-203.
http://www.ncbi.nlm.nih.gov/pubmed/20695012

"A protective association between higher vitamin D levels and the onset of multiple sclerosis (MS) has been demonstrated; however, its role in modulating MS clinical course has been little studied... Serum 25-OH-D levels were measured biannually, and the hazard of relapse was assessed using survival analysis... higher 25-OH-D levels were associated with a reduced hazard of relapse. This occurred in a dose-dependent linear fashion, with each 10nmol/l increase in 25-OH-D resulting in up to a 12% reduction in risk of relapse. Clinically, raising 25-OH-D levels by 50nmol/l could halve the hazard of a relapse."

*****

ONTARIO PROPOSAL: In June, Ontario’s Health Technology Advisory Committee (OHTAC) concluded that the routine use of Vitamin D testing could not be justified based on current evidence.

OHTAC’s membership consists of a minimum of 12 health experts, including representatives of the Ontario Medical Association and the Ontario Hospital Association.

The proposed amendment seeks to ensure that the testing provided is based on the best medical evidence, increase value for the health care system by eliminating testing that is not deemed medically necessary and promote quality and sustainability by helping to ensure that the health care system is there for future generations.

The Ministry will continue to regulate Vitamin D testing in accordance with the principle of evidence-based healthcare, and it will seek updates as required to incorporate new medical evidence. Testing would continue to be accessible as an uninsured service to Ontarians who do not meet the medical criteria, but who would still like to pay for testing.

*****

MY COMMENTS: The study cited below suggests that Vitamin D3 status should be measured for ALL patients on an annual basis. Based on all the studies provided in this submission, it is my view that at the very least, Ontario's Multiple Sclerosis sufferers must be added to the list of patients who qualify for OHIP coverage of vitamin D3 testing.

I suggest that in the long term, insured testing of vitamin D3 status will reduce spending on tests such as MRI, lumbar puncture, &c for MS patients, and who knows how many tests for the other conditions listed.

*****

STUDY: The Vitamin D Epidemic and its Health Consequences
Michael F. Holick
J. Nutr. 135:2739S-2748S, November 2005
http://jn.nutrition.org/cgi/content/abs ... 5/11/2739S

"There is mounting scientific evidence that implicates vitamin D deficiency with an increased risk of type I diabetes, multiple sclerosis, rheumatoid arthritis, hypertension, cardiovascular heart disease, and many common deadly cancers. Vigilance of one’s vitamin D status by the yearly measurement of 25-hydroxyvitamin D should be part of an annual physical examination."

*****

MY COMMENTS: Thank you again for the opportunity to provide input into this process.

I would be pleased to submit additional literature review and commentary on this proposal, if further evidence is needed to support coverage for vitamin D3 testing for Ontario’s MS patients.
Last edited by jimmylegs on Mon Sep 27, 2010 2:05 pm, edited 2 times in total.
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Re: Ontario health insurance curbs vit d testing

Postby NHE » Mon Sep 27, 2010 12:25 am

Hi Jimmylegs,
I think that this paper ties MS and vitamin D pretty well together. I may have missed it, but did you include this in your letter?

http://www.thisisms.com/ftopicp-128403.html#128403

In this prospective population-based cohort study, in a cohort largely on immunomodulatory therapy, higher 25-OH-D levels were associated with a reduced hazard of relapse. This occurred in a dose-dependent linear fashion, with each 10nmol/l increase in 25-OH-D resulting in up to a 12% reduction in risk of relapse. Clinically, raising 25-OH-D levels by 50nmol/l could halve the hazard of a relapse.


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Postby jimmylegs » Mon Sep 27, 2010 4:42 am

thanks for that NHE i'll add it in. i threw the above together pretty fast but am having trouble submitting online - i'll add it in :) thx
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Vitamin D3 rocks -- a study shows 42% reduction in relapses

Postby Rebecca » Sun Oct 10, 2010 2:50 pm

A study from South Africa actually showed that 14,000 IU per day can cut the relapse rate by 42%. This beats the MS drugs.

I love vitamin D3.
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Postby Frank » Sun Oct 10, 2010 3:31 pm

Hi Rebecca, could you please link to a source for the study in South Africa that you mentioned?

Thanks!
--Frank
Treatment: Gilenya since 01/2011, CCSVI both IJV ballooned 09/2010, Tysabri stopped after 24 Infusions and positive JCV antibody test, after LDN, ABX Wheldon Regime for 1 year.
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Low vitamin D levels linked to depression

Postby MSUK » Mon Oct 11, 2010 1:42 am

Image

Vitamin D status in patients with MS is negatively correlated with depression, but not with fatigue.

Abstract
Background -  Depressive symptoms and fatigue are frequent and disabling symptoms of multiple sclerosis (MS). Depression and fatigue have been associated with a poor vitamin D status, and a poor vitamin D status is often found in MS....Read More - http://www.msrc.co.uk/index.cfm/fuseact ... ageid/1334
MS-UK - http://www.ms-uk.org/
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Low vitamin D levels increases risk of Paediatric MS

Postby MSUK » Sat Oct 16, 2010 11:46 am

Image

Low serum vitamin D at the time of a first demyelinating event increases the risk of subsequent multiple sclerosis (MS) in children, according to a new study.

Of 208 children under age 16 who experienced an acute demyelinating episode, 41 subsequently received a diagnosis of MS an average of eight months following their first symptom. Those with MS had an average serum vitamin D level of 52 nmol/L, versus 66 nmol/L for those remaining without an MS diagnosis, according to Heather Hanwell, MSc, a PhD candidate in the Department of Nutritional Science at the University of Toronto.... Read More - http://www.msrc.co.uk/index.cfm/fuseact ... ageid/1408
MS-UK - http://www.ms-uk.org/
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Dietary intake of vitamin D during adolescence, risk of MS

Postby MSUK » Wed Oct 20, 2010 1:23 am

Image

Abstract
Adolescence may be an important etiological period in the development of multiple sclerosis (MS), and studies suggest that adequate vitamin D nutrition is protective.

Here, the authors examined whether dietary intake of vitamin D during adolescence decreases the risk of MS in adulthood. In 1986 in the Nurses' Health Study and in 1998 in the Nurses' Health Study II (NHSII), women completed a food frequency questionnaire regarding their dietary intake during adolescence. From this, daily intake of vitamin D was calculated......Read More - http://www.msrc.co.uk/index.cfm/fuseact ... ageid/1334
MS-UK - http://www.ms-uk.org/
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Vit D.....(JL?)

Postby Bubba » Wed Oct 20, 2010 4:26 pm

I got myblood test paper in the mail today. It said I need to immediately start with 4000iu of vitamin D a day. I have been taking 2000iu a day for a year, and I thought that was too much? JL, what do you think of 4000 a day.My score was 34, bottom line being 30?
w/m 44
The problem comes with the decision of weighing the unknown with the unknown.
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Postby Daisy3 » Wed Oct 20, 2010 4:39 pm

My other half was told to take 4/5000iu a day. Even 10,000iu per day was seen as a good amount to take. His neurologist thought the first amount mentioned was conservative. Go ahead and take what you have been told and then some more.
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Postby jimmylegs » Wed Oct 20, 2010 5:01 pm

heya bubba, 4000 IU is considered a long term *maintenance* dose, so that would indicate that 2000 IU is draining your levels over time.

also, what's your mineral intake like, ie calcium, magnesium, and zinc?
if you're not taking minerals with your D3 supplement your body probably won't deal with it properly.

also, i found when i corrected zinc deficiency that my body's response to D3 supplementation tripled. it was crazy.

unfortunately, hydrating with beer saps your body's zinc so you'll likely have to take extra to optimize your serum levels! ;D

anyway i'd say go with the doc's recommendation of 4000 IU/d of D3, but start paying attention to zinc levels too. see if you can get both Zn and D3 tested at the same time.

over the next while, you could see if you can get serum zinc up to 18.2-18.4 umol/L, and evaluate whether your dose response to D3 improves in step with zinc optimization.

aim for 40-50 serum D3 (or 100-150 for those who speak in nmol/L)

HTH! let me know how things pan out :)
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Postby Bubba » Thu Oct 21, 2010 5:33 pm

jimmylegs wrote:heya bubba, 4000 IU is considered a long term *maintenance* dose, so that would indicate that 2000 IU is draining your levels over time.

also, what's your mineral intake like, ie calcium, magnesium, and zinc?
if you're not taking minerals with your D3 supplement your body probably won't deal with it properly.

also, i found when i corrected zinc deficiency that my body's response to D3 supplementation tripled. it was crazy.

unfortunately, hydrating with beer saps your body's zinc so you'll likely have to take extra to optimize your serum levels! ;D

anyway i'd say go with the doc's recommendation of 4000 IU/d of D3, but start paying attention to zinc levels too. see if you can get both Zn and D3 tested at the same time.

over the next while, you could see if you can get serum zinc up to 18.2-18.4 umol/L, and evaluate whether your dose response to D3 improves in step with zinc optimization.

aim for 40-50 serum D3 (or 100-150 for those who speak in nmol/L)

HTH! let me know how things pan out :)



Well I was taking what you reccomended, but remember I quit the zinc causw it wasmaking me sick... maybe I need to try it in smaller doses?
w/m 44
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Postby jimmylegs » Thu Oct 21, 2010 5:52 pm

possibly bubba.. how much zinc were you taking in one shot? did you take it on an empty stomach or with a meal? i remember getting sick from zinc when i first started - i took 100mg all at once. had to back off to 50mg with meals, twice a day. now i just take 50mg 1x per day, normally. some people probably only need 25mg or less per day. as long as the serum level is 18.2 - 18.4 umol/L (or the higher teens will do .. i recently saw a new study with numbers in healthy controls up into the 19 range.. will have to post that one). hope that helps bubba!
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Postby Wonderfulworld » Fri Oct 22, 2010 2:37 am

Hi Bubba
I take 4000IU as a maintenance dose all the time now, with my neurologists' approval and GP's - like yourself once I went to 2000IU my D3 went below normal again.

The excellent JL 8) gave me the advice about dividing up the dose and Cal/Mag/Zinc and it is only when I followed this advice that my levels of D3 came up to the normal range so the Zinc is a factor.

My schedule is:
Morning - Multivitamin/mineral with 400IU D3 in it.
During the day sometime - 3000IU Vit D3 and 250g Magnesium
Later on: Zinc tablet (50% RDA)
Evening: Cal/Mag tablet going to bed think there's 500mg Cal/250mg Mag.

I've followed this for a while now and I'm going to get re-tested again in the early new year for D3 and Zinc levels.
Hope that helps - I do think the D3 keeps the MS at a lower level of activity - whenever my D3 levels drop I have worse MS.
~~~~~~~~~~~~~~~
Concussus Resurgo
~~~~~~~~~~~~~~~
RR-MS dx 1998 and Coeliac dx 2003
~~~~~~~~~~~~~~~
Copaxone, Cymbalta. EPO, Fish Oils, Vitamin D3 2000 IU daily, Cal/Mag/Zinc, Multivitamin/mineral, Co-Enzyme Q10, Probiotics, Milk Thistle.
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Relationship between vitamin D during perinatal development

Postby MSUK » Wed Oct 27, 2010 1:12 am

Relationship between vitamin D during perinatal development and health

Image

Vitamin D deficiency is a highly prevalent condition that is present in 40% to 80% of pregnant women.

There is emerging evidence that vitamin D deficiency may be a risk modifying factor for many chronic diseases, including osteomalacia, rickets, multiple sclerosis, schizophrenia, heart disease, type 1 diabetes, and cancer.

Heightened susceptibility to these diseases may originate in early life during the development of tissue structure and function.... Read More - http://www.msrc.co.uk/index.cfm/fuseact ... ageid/1334
MS-UK - http://www.ms-uk.org/
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