Gabby Simmons Preventative Health of Multiple Sclerosis- Vitamin D Exposure Literature Review

Multiple Sclerosis (MS) is a demyelization of the central nervous system (CNS). It could be fatal once in the progressive stage, but most MS is relapsing and patients cycle through periods of affected and non-affected times. Most Epidemiological studies agree that genetics is not the only risk factor associated with the diagnosis of MS (Ascherio, 2010). Most common environmental factors listed are Vitamin D deficiency, cigarette smoking, and co-morbid infections like with the Epstein Barr virus. Smoking and Epstein Barr virus have been shown to directly affect MS, while Vitamin D levels are harder to control for and more difficult to correlate directly (Ebers, 2008). The reason why Vitamin D is considered as a link to MS is that it provides an explanation for the latitudinal phenomenon of MS prevalence. Increasing latitude increases the prevalence of MS, at the equator MS is rare (Ascherio, 2010). In Switzerland it was found by that people living at higher altitudes had less cases of MS than those living at lower altitudes. Altitude is a marker of sun intensity. Also in Norway it was found that people who live on the coast had lower MS levels than those inland inhabitants. Again vitamin D can explain this pattern; the diet of oily fish on the coast is heavy with supplemental vitamin D. Epidemiological studies of Vitamin D levels and MS have been conducted in retrospective, prospective, and case-controlled fashions. All of which include limitations and unavailable biases. In a retrospective study looking at workspace sunlight exposure and MS death examined death certificates of people deceased from MS (Asheri and Munger, 2007). A limitation of the study included the inaccuracy of death certificates and

publically recorded data. This could have included the reason for death and the occupation of the person was not accurate. Occupation was divided into outdoor, mixed, and indoor. The results showed a strong correlation with more sunlight and less MS fatalities. MS and vitamin D exposure have also been compared in prospective cohort studies. These are over a long period of time and costly. A well-cited study by Munger et al. in 2006 covered 12 years to see if participants develop MS and then compared two non MS diagnosed serum 25-hydroxyvitamin D, a concentration marker of vitamin D advisability to tissues including immune system measured in blood, with an MS patients 25(OH)D concentration from a time before their initial diagnosis. It was found the inverse relation with multiple sclerosis risk and vitamin D levels was particularly strong for 25-hydroxyvitamin D levels measured before age 20 years. So early sunlight exposure could be important to determine the risk factor for MS. More commonly conducted are case- control studies; here the distribution of exposure among MS cases is compared with that of a group of controls, individuals who do not have MS. Case-controlled studies have multiple biases including selection bias of the control group- participants have different distribution of exposure not only limited to sun when compared to the experimental group. Another bias is a recall bias- not relaying past experiences accurately. In parallel to what Munger et al. 2006 found, with the importance of childhood sunlight exposure phone interviews are used in many studies to recall childhood outdoor activity (Asherio and Munger, 2007). However (Ebers, 2008) rejected the idea that MS can be linked to childhood sun exposure.

To truly link Vitamin D exposure and MS doctors have called for randomized placebo clinical trial with vitamin D supplementation (Hughes, 2003). Hesitations include controlling participants for additional vitamin D sources, like the sun, and ethical debates. Polman et al. 2008 listed restrictions that should be adhered to when MS patents are part of a placebo group: subjects must refuse to use these treatments, have not responded to them, or they can participate if these treatments are not available for economic reasons. However I would like to question these recommendations for an ethical MS placebo study, supplementation is not expensive so this would not be a consideration for potential placebo patents in this study. Also the placebo patients would have no negative effects working on them, only not receiving a potential improvement. I think a placebo group is ethically warranted if that is made clear and the patents are comfortable not to receive the experiential drug, I do not agree that the patents have to strongly refuse the treatment.

Bibliography

1. Ascherio, A. et al. Vitamin D and multiple sclerosis. June 2010. The Lancet
Neurology. 2. Asherio, A and Munger, K.L. Environmental Risk factors for multiple sclerosis. Part II: Noninfectious Factors. June 2007. Harvard Department of Nutrition. 3. Ebers, G.C. Environmental Factors and Multiple Sclerosis. March, 2008. Oxford Department of clinical neurology. 4. Hayes, E.C. Vitamin D: a natural inhibitor of multiple sclerosis. 2000. Department of biochemistry, university of Wisconsin- Madison. 5. Hughes, Sue. Vitamin D for All to prevent MS? Oct. 3, 2013. Web. Nov. 12, 2013. http://www.medscape.com/viewarticle/812045#2 6. Multiple Sclerosis: Overview. Utah Medical Library. Web. Nov 14, 2013. http://library.med.utah.edu/kw/ms/overview.html 7. Munger, K.L et al. Serum 25- Hydroxyvitamin D levels and risk of multiple sclerosis. 20 Dec. 2006. American medical association. 8. Polman, C.H. et al. Ethics of placebo-controlled clinical trials in multiple sclerosis. 18 June, 2008. American Academy of Neurology.