Tag: Vitamin D

#MSCOVID19: vitamin D & zinc

I have already made the case for pwMS to prehabilitate, i.e. to prepare themselves for getting COVID-19. You can read my proposed prehabilitation programme on MS-Selfie. One of the topics I cover is diet and I mention that you should ensure that you are vitamin D (vD) replete. There are three ways to do this. (1) The first is to get a healthy daily exposure to sunshine (~20mins of upper body exposure around midday in summer), which can be difficult if you are disabled and stuck indoors and it is winter where you live. 

(2) Another source of vD is eating foods that are high in vD, for example, fatty fish. However, even the latter is often insufficient to raise your blood levels above 75 or 80 nmol/L, which are the two most common lower levels of normal used by UK laboratories. If you apply evolutionary medicine principles, i.e. what are the vD levels in hunter-gatherers or people who work outdoors,  a level of above 100 nmol/L is probably normal. (3) The easiest way to get above 100nmol/L is with dietary supplements. I have always recommended the Vitamin D Council’s advice which is to take 5,000 U of vD3 per day. I note that the Vitamin D Council’s website has gone offline and I don’t know why. Does anybody know the reason? 

The following small study below from Indonesia shows that low vD levels were associated with a higher chance of dying from COVID-19. As with all studies of this nature, it could be reverse causation, i.e. COVID-19 patients with the greatest level of inflammation in their lungs consumed more vD as part of the inflammatory process. In other words, inflammation caused the low vD levels not the other way round. I am prepared to go as far as saying that in inflammatory or infectious diseases the lower the vD levels the worse the prognosis; this is called the consumptive vD hypothesis of inflammation.

What is needed is a clinical trial to see if vD supplements prevent you from getting severe COVID-19. This type of trial is very difficult as a large number of the population are already taking vD3 supplements and a lot of vD experts will say we don’t have equipoise in that they think people should be vD replete for general health reasons regardless of COVID-19. 

As low dose vD3 supplementation is safe and most of the UK population is vD deficient I would advise taking vD supplements rather than not taking them. Do you agree? 

I am also asked what other supplements should you take? If you have a healthy balanced real food diet you don’t need to take any other supplements. However, if you eat an unbalanced diet for humans, for example, a purely plant-based diet, I would advise you to review your micronutrient intake. While not all vegans have low blood levels of zinc, a recent review showed that vegetarians — and especially vegans — have lower zinc intakes and slightly lower blood levels of zinc than omnivores. I focus on zinc because zinc deficiency is associated with an increased risk of infections and complications of infections. There is also a hypothesis that zinc may act against SARS-CoV-2 at several different points in its replicative cycle (see the article from below) and zinc is also important for anti-bacterial activity. A large number of COVID-19 deaths are due to secondary bacterial pneumonia.

A supplemental dose of 5mg or 10mg per day of zinc should be sufficient with other dietary sources to ensure you are zinc replete. 

In the absence of a SARS-CoV-2 vaccine and an effective antiviral are you ready yet to get COVID-19? If not you need to start today. Prehabilitation is an attempt to lower your chances of getting severe COVID-19 and dying from the complications of COVID-19. If you haven’t please act now!

Vitamin D – the sunshine vitamin

Raharusun et al. Patterns of Covid-19 Mortality and Vitamin D: An Indonesian Study. SSRN April 26, 2020.

This is a retrospective cohort study which included two cohorts (active and expired) of 780 cases with laboratory-confirmed infection of SARS-CoV-2 in Indonesia. Age, sex, co-morbidity, Vitamin D status, and disease outcome (mortality) were extracted from electronic medical records. The aim was to determine patterns of mortality and associated factors, with a special focus on Vitamin D status. Results revealed that majority of the death cases were male and older and had pre-existing condition and below normal Vitamin D serum level. Univariate analysis revealed that older and male cases with pre-existing condition and below normal Vitamin D levels were associated with increasing odds of death. When controlling for age, sex, and comorbidity, Vitamin D status is strongly associated with COVID-19 mortality outcome of cases.

Zinc – an essential micronutrient

Skalny et al. Zinc and Respiratory Tract Infections: Perspectives for COVID‑19. Int J Mol Med. 2020 Apr 14. doi: 10.3892/ijmm.2020.4575.

In view of the emerging COVID‑19 pandemic caused by SARS‑CoV‑2 virus, the search for potential protective and therapeutic antiviral strategies is of particular and urgent interest. Zinc is known to modulate antiviral and antibacterial immunity and regulate inflammatory response. Despite the lack of clinical data, certain indications suggest that modulation of zinc status may be beneficial in COVID‑19. In vitro experiments demonstrate that Zn2+ possesses antiviral activity through inhibition of SARS‑CoV RNA polymerase. This effect may underlie therapeutic efficiency of chloroquine known to act as zinc ionophore. Indirect evidence also indicates that Zn2+ may decrease the activity of angiotensin‑converting enzyme 2 (ACE2), known to be the receptor for SARS‑CoV‑2. Improved antiviral immunity by zinc may also occur through up‑regulation of interferon α production and increasing its antiviral activity. Zinc possesses anti‑inflammatory activity by inhibiting NF‑κB signaling and modulation of regulatory T‑cell functions that may limit the cytokine storm in COVID‑19. Improved Zn status may also reduce the risk of bacterial co‑infection by improving mucociliary clearance and barrier function of the respiratory epithelium, as well as direct antibacterial effects against S. pneumoniae. Zinc status is also tightly associated with risk factors for severe COVID‑19 including ageing, immune deficiency, obesity, diabetes, and atherosclerosis, since these are known risk groups for zinc deficiency. Therefore, Zn may possess protective effect as preventive and adjuvant therapy of COVID‑19 through reducing inflammation, improvement of mucociliary clearance, prevention of ventilator‑induced lung injury, modulation of antiviral and antibacterial immunity. However, further clinical and experimental studies are required.

CoI: multiple

The war on sugar (more posts below today)

Barts-MS rose-tinted-odometer ★★★ 

Just back from the NMSS ‘Pathways to Cures’ meeting in Washington DC during which we pledged to  STOP, RESTORE and END multiple sclerosis. 

The END refers to prevention. We discussed at the meeting modifiable risk factors that could be tackled to reduce the incidence (new cases) of MS and one risk factor childhood and adolescent obesity. One theory has been that obesity affects MS risk by interacting with vitamin D (vD); either by lowering levels due to the breakdown of vD in fat or secondary to systemic inflammation associated with obesity. 

In this genomics study below it is clear that obesity itself increases your risk of MS and is independent of vD levels. 

So how do we tackle obesity and the obesity epidemic? It is clear that obesity is caused by sugar and the change in the dietary guidelines that occurred in the 1970s and 1980s when governments launched a war on fats and started to promote a low-fat diet as being ‘heart-healthy’. We now know that the low-fat diet was wrong and that what was driving heart and vascular disease was processed carbohydrates, in particular, sugar consumption, and not saturated fats. Fortunately, the world is now beginning to acknowledge that saturated fats are healthy and that processed and ultra-processed foods, which are largely made up of carbohydrates and polyunsaturated fats are unhealthy culprits and are what is causing the obesity epidemic. 

This graph shows you the strong association between per capita sugar consumption and obesity. It is extraordinary that politicians are not doing more to tackle global sugar consumption.

Another factor driving obesity is our sedentary lifestyle and reduced exercise. 

To tackle obesity we need governments to declare ware on sugar and the food industry and to put in place national policies to tackle our sedentary lifestyle. This is easier said than done. Politicians are not as powerful as they used to be; most of them rely on lobby money to get elected and once elected they represent the vested interest groups that got them elected. Sadly this often includes sugar money. 

The sugar industry is heavily subsidised, which keeps the price of sugar artificially low. Sugar subsidies interfere with the global market and have resulted in a sugar glut. This is one of the reasons why junk food is so cheap and real-food is so expensive. 

Obesity is not only a risk factor for causing MS it also affects people with established MS.  Obesogenic diets cause a metabolic shitstorm that impacts on MS indirectly. Obesity causes metabolic syndrome (hypertension, insulin resistance, glucose intolerance, diabetes and dyslipidaemia) and a systemic inflammatory syndrome that worsens MS. Therefore, there is a good reason why, if you are obese you should consider doing something about it. 

I recommend you read “Why we get fat and what to do about it”, by Gary Taubes or you can watch one of his lectures on YouTube. Understanding the metabolic issues that underlie obesity will allow you to understand what to do about it.

Then there is the responsibility you have to your siblings, children and relatives. If you have MS your direct family are at increased risk of getting MS and you should get them to modify their risk factors, i.e. make sure they stay slim, or if they are obese they need to lose weight, get them to exercise and to start taking vD supplements. Tell them about the link between smoking and MS; they should either stop smoking or get them to pledge not to start smoking in the future. 

MS prevention is about education, education, education and education begins in the home. We estimate that ~15-20% of new cases of MS could be prevented by preventing childhood obesity and smoking. This is why we need to declare war on sugar and smoking as part of our END MS campaign. Do you agree?

Jacobs et al. BMI and Low Vitamin D Are Causal Factors for Multiple Sclerosis: A Mendelian Randomization Study. Neurol Neuroimmunol Neuroinflamm, 7 (2) 2020 Jan 14.

Objective: To update the causal estimates for the effects of adult body mass index (BMI), childhood BMI, and vitamin D status on multiple sclerosis (MS) risk.

Methods: We used 2-sample Mendelian randomization to determine causal estimates. Summary statistics for SNP associations with traits of interest were obtained from the relevant consortia. Primary analyses consisted of random-effects inverse-variance-weighted meta-analysis, followed by secondary sensitivity analyses.

Results: Genetically determined increased childhood BMI (ORMS 1.24, 95% CI 1.05-1.45, p = 0.011) and adult BMI (ORMS 1.14, 95% CI 1.01-1.30, p = 0.042) were associated with increased MS risk. The effect of genetically determined adult BMI on MS risk lessened after exclusion of 16 variants associated with childhood BMI (ORMS 1.11, 95% CI 0.97-1.28, p = 0.121). Correcting for effects of serum vitamin D in a multivariate analysis did not alter the direction or significance of these estimates. Each genetically determined unit increase in the natural-log-transformed vitamin D level was associated with a 43% decrease in the odds of MS (OR 0.57, 95% CI 0.41-0.81, p = 0.001).

Conclusions: We provide novel evidence that BMI before the age of 10 is an independent causal risk factor for MS and strengthen evidence for the causal role of vitamin D in the pathogenesis of MS.

CoI: this work was done by our Preventive Neurology Unit

Are nutritional supplements a waste of money?

Do you take dietary supplements? If yes, are you prepared to review what you are taking and ask yourself if you need to spend the money taking something that is not supported by any evidence?

In the US the Food and Drug Administration (FDA) has recently announced measures to regulate dietary supplements.

The FDA Commissioner Scott Gottlieb said: “It’s clear that the US Food and Drug Administration plays an important role in helping consumers make use of safe, high-quality dietary supplements while also protecting Americans from the potential dangers of products that don’t meet the agency’s standards for marketing. He continued: “I’m concerned that changes in the supplement market may have outpaced the evolution of our own policies and our capacity to manage emerging risks. To continue to fulfil our public health obligations we need to modernize and strengthen our overall approach to these products. Toward these goals, the FDA is committing to new priorities when it comes to our oversight of dietary supplements at the same time that we carefully evaluate what more we can do to meet the challenge of effectively overseeing the dietary supplement market while still preserving the balance struck by Dietary Supplement Health and Education Act.”

The FDA’s priorities will include (1) communicating better about safety issues related with dietary supplements and (2) establishing a regulatory framework to promote innovation, as well as upholding product safety and (3) creating new strategies of enforcement.

Earlier this month, the FDA posted 12 warning letters and five online advisory letters to US and international companies, which are illegally selling more than 58 products, primarily dietary supplements, as treatments for serious health conditions, when their safety and efficacy is unknown.

Gottlieb stated: “Science and evidence are the cornerstone of the FDA’s review process and are imperative to demonstrating medical benefit, especially when a product is marketed to treat serious and complex diseases like Alzheimer’s. Alzheimer’s is a challenging disease that, unfortunately, has no cure. Any products making unproven drug claims could mislead consumers to believe that such therapies exist and keep them from accessing therapies that are known to help support the symptoms of the disease, or worse as some fraudulent treatments can cause serious or even fatal injuries. Simply put, health fraud scams prey on vulnerable populations, waste money and often delay proper medical care – and we will continue to take action to protect patients and caregivers from misleading unproven products.”

The advice above applies to people with MS. We have no evidence that pwMS need to take any supplements. If you eat a healthy balanced diet, for example the Mediterranean diet, you don’t need supplements. The only supplement I routinely recommend to my patients is vitamin D (vD). Why? There is no evidence that vD makes any difference to the outcome of your MS, but it has a role to play in bone health. We know that pwMS are more likely to have thin bones (osteopenia and osteoporosis) and are much more likely to suffer falls and fractures. Extrapolating data from the studies in elderly women we recommend pwMS keep themselves vD replete. We also know that the vast majority of our patients with MS are vD insufficient or deficient. Why? They don’t get enough sunlight exposure to manufacture their own vD in their skin or enough vD from their diets. Recommending vD supplementation is therefore not really evidence-based; we need to do trials to see if it helps prevent fractures in pwMS.

Please let us know what supplements you are using and who recommended them?  We really need to debate this issue. Too many of my patients can’t afford to make ends meet; not wasting money on unproven supplements is one-way of saving money.