Fibromyalgia, Multiple Sclerosis, and Vitamin D Deficiency

by Scott Grivas, M.D. and Bonnie Mattheus, R.N. Misdiagnosis of Fibromyalgia and Nonspecific Chronic Pain Dr. James Richardson noted in his editorial in the American Family Physician in Jan. 2005 that “Until Vitamin D deficiency is quite severe, adults who are deficient in vitamin D may have chronic pain and lower extremity weakness. Indeed, women who are deficient in Vitamin D often are misdiagnosed with fibromyalgia or even somatization syndromes.” Add to that what authority Michael Horlick wrote in the American Journal of Clinical Nutrition in 2004, that “more than 90% of 150 (people) who presented with nonspecific muscle aches and bone aches and pains at a Minnesota hospital were found to be vitamin D deficient.” Bonnie Mattheus: My Story But when my story began, I didn’t know the facts above. It would have made me feel better mentally and have given direction to therapy, but I’m getting ahead of myself. Over a year ago I was having a medical visit with my doctor, Scott Grivas. He knew I had been struggling with what had been diagnosed as post-traumatic fibromyalgia, (in other words, after a whip lash injury, the doctor found I was “positive” for pain in 18 of the 18 trigger points used to identify “fibromyalgia”). I have forgotten why I had an appointment that day, but I know it wasn’t for the fibromyalgia. As he went over my symptoms, Dr. Grivas decided to do a test for vitamin D deficiency. Now I’m a nurse, and it was the end of summer. Nearly every day I worked outside in my acre of yard. I had also been ingesting two times the normal MDR (minimal daily requirement) of vitamin D in my multiple vitamin. So, I persuaded Dr. Grivas not to do the test since my risk was so minimal (and I don’t like needles.) Six months later, I had to visit my gynecologist who also focused on preventing and treating osteoporosis. She didn’t discuss, but simply ordered a blood draw; among the tests she ordered was a vitamin D level. To my surprise, when I went back in for the results, she found that I was vitamin D deficient and started me on an aggressive supplementation program. Dr. Grivas had been right! I should have listened to him months earlier and had the test. What he knew, and what I had not thought of, was my older age(which reduces skin efficiency in producing vitamin D). In addition, I live in the northern hemisphere where U.V. sun rays are not very available for large portions of the year.With vitamin D supplementation, my “fibromyalgia” has not completely disappeared, but my pain level has gone down so much I rarely notice it any more. What’s strange is that my allergies are also much less problematic now too. Dr. Grivas’ Turn I recall a couple of rather dramatic cases. A middle aged lady came to me complaining of miserable body aches and pains, with no apparent reason. She had been diagnosed with fibromyalgia. We just couldn’t identify the problem. She could barely get around, and her movement was difficult, with diffuse musculoskeletal aches. I had blood drawn for a vitamin D level test. When the results came back, she had so little that it was almost non-detectable. I supplemented her with an oral vegetable based vitamin D. Her relief was remarkable. Suddenly life took on a whole new meaning for her. A second interesting case was a middle aged female with Multiple Sclerosis who came to see me complaining of weakness, numbness, and tingling of her right arm. After lab evaluation, she was discovered to have coincidental vitamin D deficiency. After vitamin D supplemental therapy, hydrotherapy, and anti-inflammatory herbal agents, she dramatically improved in neuromuscular function. Does she still have M.S.? Yes, but she is so very much better. (Having one diagnosis does not protect us from other diseases or nutritional deficiencies. In fact, it may predispose us to them.) This is particularly true with vitamin D deficiency. As a person becomes sicker, the tendency is to stay indoors. That is when what you really need is to get outdoors into the sunshine. Scott Grevis is the Medical Director for Wildwood Lifestyle Center and Hospital, Wildwood, Georgia. He not only sees patients but is active in teaching physicians in America and around the world . Bonnie Mattheus, a RN, adjunct faculty member of Southern Adventist Univeristy, and president of Bon Herbals and Wonderful Things, Inc. writes from Collegedale, Tennessee. Vitamin D Deficiencies: a New Pandemic Part II by Scott Grivas, M.D. and Bonnie Gibson Mattheus, R.N. Recap and intro: In the first part of this article, vitamin D was noted to be a hormone and not a vitamin at all. Researchers currently find vitamin D deficiency around the world in 20-100% of the population. This is markedly related to where the study was conducted and how much sun gets through at that latitude. Vitamin D is essential for the absorption of calcium, which is, itself, indispensable for nerve and muscle function. Therefore, severe vitamin D deficiency may be associated with osteoporosis and a variety of musculoskeletal (muscle and bone) complaints. Today, many physicians are testing patients suffering with chronic musculoskeletal pain for vitamin D deficiency and are often finding that this is a contributing factor to the pain. For example, “fibromyalgia” and “chronic fatigue syndrome” are often associated with vitamin D deficiency and may improve with sunshine and vitamin D supplementation. Who are the people most at risk for developing Vitamin D deficiency: • The fastest growing population group in America: The elderly. The skin loses its ability to synthesize vitamin D by as much as 75% by age 70, Michael Holick reported in 2004. Home bound older adults are particularly at risk, says James Richardson (2005). • The chronically ill. As soon as people get sick, they tend to crawl into bed and stay indoors. “Every patient should be taken out-of-doors daily if there is any way possible,” Dr Grivas says. “Get them out-of-doors in the sunshine and fresh air, the true physicians.” • Malnutrition. Malnutrition caused by inadequate dietary intake of nutrients, inflammatory diseases of the small bowel or pancreas, resection of the bowel, or by-pass procedures may result in significant deficiencies of calcium and vitamin D. • The obese. This is also a group that is growing rapidly in America. The CDC recognizes obesity as a national epidemic and a major health concern. Vitamin D is a fat soluble substance that is accumulated in the large body fat stores making it unavailable for easy utilization. • Anyone with limited sunlight exposure: Clothing, sunscreen usage, staying indoors for work and leisure, glass shielding or living above or below the 37 degree latitude either north or south have reduced penetration of the U.V. ray. These all have their effect in limiting sunlight activation of vitamin D precursors in the skin, thus contributing to vitamin D deficiency. (Holick, 2006). • Persons with darkly pigmented skin require 3-6 times more sun exposure than fair skinned persons. Michael Holick noted that the person most at risk was the older female, of African-American descent, at the end of winter, particularly if they stay mostly indoors. In the American Family Physician, January 2005, James Richardson, M.D., M.P.H., chief of geriatric medicine at Union Memorial Hospital, said up to 84% of elderly black females are found to be Vitamin D deficient. • Persons with a history of kidney or liver disease are at increased risk for vitamin D deficiency because both of these organs play a critical role its manufacture. • Those using certain medications such as anticonvulsants (like Dilantin and Phenobarbital), corticosteroids (like Prednisone and Cortisone), Rifampin (a bactericidal, anti- tubercular drug.) Now go back and count how many of these factors apply to you. Any one is a major factor, but if you have several factors, your risk for vitamin D deficiency is multiplied. Other diseases related to vitamin D deficiency: M.F. Holick, PhD, M.D., one of many authors who contributed to the second edition of the Encyclopedia of Human Nutrition, wrote “Essentially every cell and organ in the body requires vitamin D, i.e., they all have a VDR ( a vitamin D receptor).” And that gives us an explanation as to all the other things that research is learning about this amazing essential hormone. In 2006, Holick reviewed 264 published research findings in the Mayo Clinic Proceedings. He concluded that adequate vitamin D levels aide in preventing cancer. That is interesting, as the elderly have the greatest risk of vitamin D deficiency and the highest risk of cancer. Vitamin D deficiency is related to an increased risk of hypertension, cardiovascular diseases, diabetes, psoriasis, and multiple sclerosis. Interestingly, increased risk for multiple sclerosis is also related to a lack of vitamin D during childhood. (5) Apparently adequate sunshine in childhood is protective against this disease which currently has no cure.Vitamin D deficiency is implicated in rheumatoid arthritis, inflammatory bowel disease, systemic lupus erythematosus, osteoarthritis, and periodontal disease. Who would have guessed? But then Holick did say that it was related to “every cell in the body.” How is vitamin D measured? A laboratory test done on the blood can measure the amounts of available vitamin D in the body. Usually it will measure the vitamin D2 and the vitamin D3 to give a combined result of total vitamin D in the blood. Old standards of interpretation considered anything from 20-100 ng/mL was normal. Newer standards are suggesting that a score below 32 is a deficiency, and as always, going for the middle of the range is a good target goal.Dr. Grivas recommends the 40-50 range as a target. Stay in the middle of the road. What can be done about vitamin D deficiency or insufficiency? Sunshine. No doctor’s order is required for the simplest, cheapest solution of all. Get out into the sunshine every day that you can. This will meet the needs of most people. How much sunshine do you need? The old recommendations suggested exposure of the hands and face for ten to fifteen minutes a day. Researchers now suggest that is less than adequate. Michael Holick in 2006 compiled multiple findings and concluded that the arms and legs need to be exposed to sunshine, not just the face and hands. Remember when the skin produces what we need, increased sun exposure does not create Vitamin D toxicity, though sun burn is a risk and should be avoided. Mrs. E. G. White, a health reformer in her day, said over a hundred years ago, “If all our workers were so situated that they could spend a few hours each day in outdoor labor, and felt free to do this, it would be a blessing to them; they would be able to discharge more successfully the duties of their calling. If they have not time for complete relaxation, they could be planning and praying while at work with their hands, and could return to their labor refreshed in body and spirit.” {Gospel Workers, p 240.2} While this applies to vitamin D production, it also applies to much broader beneficial effects of sunshine and time spent out of doors. Nutrition, what you eat, can also be a non-prescription source of vitamin D. However, Dr. Holick noted that very few foods contain Vitamin D naturally. Oily fish such as salmon contains 400 IU per 3.5 oz, cod liver oil 400 IU/teaspoon; and mackerel and sardines have long been recognized as a source of vitamin D. The use of fish products carries its own risk of increased incidence of disease. Irradiated mushrooms are considered a good source. There are some foods fortified with vitamin D. This includes milk, some orange juice, some breads and cereals. Egg yolks have 20 IU (plus cholesterol). Fortified milk has 100 IU per 8 ounces. Some yogurts contain 100 IU per serving. With the increase in BSE (Bovine Spongiform Encephalopathy), also called “mad cow” disease, and its counterpart in the human, CJD (Variant Creutzfeldt-Jakob Disease,) many people feel this dairy source for vitamin D poses too great a risk. Read the labels on foods you buy. As a general rule, dietary availability of this hormone is limited in foods. Further, the labels do not always say which form of vitamin D has been added. Supplementation and prescription vitamin D can be used. We suggest that the source be considered when choosing to use supplements. While vitamin D2 (ergocalciferol) and Vit D3 (cholecalciferol) both lead to increased blood levels of vitamin D, Dr. Grivas recommends the plant-derived vitamin D2 as being the safer product with decreased risk of animal-carried disease. There is some evidence that D3 in the same doses increases 25(OH) Vitamin D (calcidiol) more than D2. However, Dr. Grivas does not feel that the difference is great enough to warrant going to an animal based vitamin D. Linus Pauling Institute at Oregon State University at http://lpi.oregonstate.edu/infocenter/vitamins/vitaminD/ may be of interest if you want to check things out for yourself. It has 100 of the top research articles and is recently updated. How Much? In 2005, Holick felt there was consensus that the range of need for vitamin D was still estimated as 200 IU for infants under 6 months of age up to 600 IU for persons over 70 years of age (average of 400 I.U., regardless of age). He felt that sunshine should be the first thing to try, not oral supplementation. Vitamin D toxicity Vitamin D is considered to be fat soluble and fat stored, creating a potential for toxicity. Toxicity has only been observed when dietary or supplemental intake exceeded daily doses of 5,000 IU over several months, Holick said. Doses of 4000 IU per day for 3 months and 50,000 IU per week for 2 months have been administered without toxicity. Excessive amounts of vitamin D can cause hypercalcemia and hypercalciuria with an increased risk of kidney stones and soft tissue calcification. And again, remember that sunshine produced vitamin D does NOT result in toxicity. 12-9-09 (latest update) The amount of supplementation needed is the object of much research and the amounts that are recommended keep rising. It is an issue of much debate. Today, Dr. Grivas says that you can safely take 2,000 IU every day year round without a doctor to supervise. Many researchers are calling for the MDR (minimal daily requirement) to be raised to 5,000 IU of vitamin D daily. Dr. Grivas feels that if you need to use the higher dosages, that for the sake of safety, a knowledgeable physician should periodically check the blood level of vitamin D and adjust the amounts. Naturally we need more in the winter months in the Northern hemisphere. Look at a map of the United States. Find Atlanta, Georgia. If you live further north than Atlanta, the essential UV rays can’t get to you in winter because of the tilt of the earth. Smog and clouds may also interfere with UV penetration of the atmosphere. Increased clothing for warmth, obviously also covers the skin so that it cannot receive the sunshine and convert cholesterol into vitamin D. In Summary: 1. Vitamin D deficiency is in the differential diagnosis list (you ought to check for it) for persons presenting with diffuse musculoskeletal pain and/or weakness, including a diagnosis of fibromyalgia & chronic fatigue syndrome. 2. Vitamin D deficiency must be suspected in any patient with osteopenia, osteoporosis or bone fragility, in hospitalized patients, and those who are chronically ill. High risk groups include the elderly, those working primarily indoors, and those who are dark-skinned. 3. If you have increased risk for vitamin D deficiency, your doctor can order a blood level to check. 4. Sunshine is the cheapest and usually best method of treatment, as it does not create toxicity. 5. Being outside to get the sunshine has many additional beneficial side effects related to mood and general health. The wise man said “Truly the Light is sweet, and a pleasant thing it is for the eyes to behold the sun” Ecclesiastes 11:7 When you can, go enjoy it.