Thursday, April 28, 2011

Standing on the Sun Will Not Prevent Depression

Vitamin D. What a roller coaster. There's the Vitamin D Council telling you to aim for a level of 60-80 ng/ml, and then the Institutes of Medicine rather grumpily suggest 20 is sufficient with a monstrous report no one has time to read except Chris Masterjohn. Vitamin D Council says no risk of toxicity below 150 - Chris Kresser, Paul Jaminet, and Kurt Harris talk about lack of randomized controlled trials and suggest somewhere between 20-50 as a good range (depending on the expert and depending on your skin color), and there is risk of kidney stones, calcification, and premature aging at higher levels. As I am a (very) pale woman, and I have looked at a bit of the pregnancy and cancer literature, I tend to think, hey, pale pregnant women might do better a bit above 50, Caucasian women should aim for 40-50, and everyone else, 30-40 is probably a good range. But Kurt makes a good point in his podcast with Chris Kresser - the 25 (OH) Vitamin D3 level we al measure is still indirect. 1,25 OH Vitamin D is the active hormone, but its metabolism is tightly regulated and levels are rarely out of a narrow range no matter how deficient we are - so who knows what a low serum level of 25 (OH) Vitamin D3 actually means in local areas, such as the brain, or in scanning for cancer cells in other sequestered areas of the body.

I don't know if I really have much of a horse in this race, though, as the data for mental health is scanty, to say the least. But the theory is sound for vitamin D to play a prominent role in mental health, as it interacts with stress hormones and nerve growth and repair, and seems especially active in those areas of the brain associated with mood, appetite, and sleep (the hippocampus and hypothalamus).

Australian researchers have been valiantly paving the way in single megadoses in seniors for years now. In the Vital D Study, 2317 women over 70 living in the community were recruited from voting rolls (which is compulsory in Australia). Women were included in the study if they had a high risk of hip fracture or previous hip fracture, osteoporosis, or high risk of low vitamin D levels. For several years, they were given a single dose of 500,000 IU Vit D3 or placebo (in 10 easy to swallow capsules) once each year in the autumn or winter, and several measures were followed along the way.

One of the measures, more fractures, proved that standing on the sun once yearly is not a terrific way to prevent them. The active group getting the vitamin D had significantly more fractures and falls.

And then there is depression. It was a lot of people, so the typical short scales were used (the GHQ-12 questionnaire). I already blew the punch line in the title. The active group had no significant difference from the placebo group in the amount of depression or change of depression with the huge bolus of vitamin D3.

Let's look more closely. The average vitamin D level for all the women at the beginning of the study was about 50 nmol/L (1 ng/ml = about 2.5 nmol/l, so the more typical 25 OH vit D3 level measurement I'm used to seeing is 20 ng/ml.) For the most part, the women in the active arm had vitamin D levels 40% higher than the placebo arm, with a level of 120 nmol/l (48 ng/ml) after dosing, and 90 nmol/l (36 ng/ml) after 3 months.

And the discussion, which is (typically) the most interesting part. The association between vitamin D and mental health is inconsistent. Epidemiology shows a correlation between low levels of vitamin D and depression. In a small fibromyalgia study, mood and fibromyalgia symptoms were not related to vitamin D levels before or after supplementation, even in those with vitamin D deficiency. In another 6 month study of older women receiving 800 IU Vit D3 and 1000 mg calcium daily, depression scores did not improve compared to placebo. In another group of folks receiving 100,000 IU Vit D3 vs phototherapy for seasonal affective disorder, Vit D3 was a clear winner. In another study of obese individuals, 20,000-40,000 vit D3 per week for a year showed a beneficial effect on depressive symptoms, though those with a baseline level > 40 nmol/L (16 ng/ml) had no benefit.

How to pull it all together? Well, 1,25 OH Vitamin D, the active form, definitely has a role in the central nervous system in neurogeneration and repair. However, the CNS may have a separate conversion system from 25 OH Vit D3 than the rest of the body. Evidence from a study I blogged about earlier suggests maybe a u-shaped curve is applicable - neonates with the lowest and highest amounts of vitamin D had the highest risk of schizophrenia later in life.

It is probably safe to say that giving 70 year old women massive doses of vitamin D3 once a year is a bad idea - bones and mental state accounted for. "Clinical studies of vitamin D in clinical populations with documented insufficiency remain warranted." And, indeed, at no time in history would we ever have been exposed to 500,000 IU vitamin D3 in a single day.

My personal clinical experience? A LOT (I'd say 1/2 to 2/3) of people who come to see me have horrible vitamin D levels. I live in the far north of the US, but it is not uncommon for levels of 12-14 ng/ml to show up on my initial tests, with the lowest I have seen being 4. I would have to say, sunshine and/or vitamin D supplementation (depending upon the season) has perked up my clinical population over a timeframe of, say, 6 months. At the same time we have implemented other interventions (nutrition, therapy, medication), so who knows what made the difference.

Is Vitamin D the end-all, be-all missing link to the question of crappy modern health and modern disease? No. Does it play a role? Most likely. But you can't overdose on vitamin D via sunshine, and you sure can via megasupplements. Vitamin D is a hormone that sticks around for a while, not something to muck around with willy-nilly. I supplemented this winter, as I was low. I'll make every effort to soak up the rays all summer. Will I supplement next winter? Probably not.

27 comments:

  1. From the reading I have done, there seems to be a physiological limit of ~10000IU that can be made in teh skin & converted with sunlight exposure. And, depending on skin type, UVB intensity, skin exposed, this might take anywhere from 5 minutes to 30 minutes in full solar noon summer sun to achieve. Exposures, in these conditions, over and above this are likely just leading to net skin damage.

    So given the above, why the hell would anyone think we have the physiological capacity to handle a half-million IU IV dose?

    My cynical side thinks that if you can show that such a large dose, given in such a manner, does show a clear benefit, then maybe you can develop a pharmaceutical vitamin D analogue/flu vax combo that can be given as a once per year jab, keeping your shareholders happy.

    I live at 43deg S and we dropped out of our UVB window probably about a month ago. So I have upped my supplementation to 4000IU on most days. By the end of the 2009/10 summer, my vitamin D levels were ~200nmol/L and I maintained myself within 150-200nmol/L over the 2010 winter. Because of this, I didn't really bother taking much in the way of supplemental vitamin D over the summer months. It also helped that, since turning to a paleo diet, I can generally tolerate more sun at solar noon without getting burnt.

    For those who are vit D deficient, I use a dosing structure of 1000IU per 15kg of body weight until they are up to the 150nmol/L litre mark. Then, depending on season, we can back it off - either completely in summer and encourage solar noon exposures, or to a dose rate of 1000IU per 20kg over winter. As many of the people I work with are overweight, as their weight drops and their stores increase, their dosing can drop quite sharply. An 80kg vitamin D deficient woman might start at 4000IU year round for the first 12-18 months as she repletes, but will likely drop to 3000IU over the autumn/winter months as her stores come back up and her weight drops.

    As you say though, often lots of other things going on at the same time, so we can't peg it all on vitamin D.

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  2. But Emily! Why can't biochemistry be simple?! :(

    Sun is simple. I can manage sun.

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  3. Very interesting. I'm very fair and freckled and before becoming Primal burned easily and quickly. I no longer burn anywhere near as quickly which is rather like magic for me and I'm already beginning to tan. I live at 57 north and have found the 10 winters I've been here difficult from around Januarya through to the end of April (when day length and sunshine pick up).

    This year, after much reading I started supplementing with vit D3 at 4,000 IUs daily - after a week I felt a marked improvement but I also started with some magnesium (300 mg) and some 5-HTP (100 mg) so too many confounds. BUT intuitively, living at my lattitudes it makes a great deal of sense that my consistent low mood appearing in the New Year fits neatly with having used up my previous summer's store of vit D.

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  4. According to Vieth taking intermittent megadoses of vitamin D would be the worst of all worlds (http://high-fat-nutrition.blogspot.com/2009/12/vitamin-d-and-uv-fluctuations.html). Also fwiw, lots of sun all the time = very paleo, megadoses of vitamin d ingested orally now and again = very unpaleo.

    Aside from the fact that the title of this post should probably be "Standing IN the sun will not prevent depression" (standing ON the sun would at least end depression one way or another) it should probably also be "megadosing with vitamin D supplements won't prevent depression" rather than "the sun will not prevent depression. For men at least, sun exposure seems to increase testosterone, so one might expect that to reduce depression and there might well be various other significant benefits just from the light exposure.

    Thanks for a great post anyway! As for myself, I can only make vitamin D from the sun at all for around 6 months of the year and think I will certainly continue to supplement to keep my levels roughly even throughout the winter.

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  5. My Vitamin D levels are horrible in recent years (Northeast) and I partially attribute it to horrid office work in a windowless cubicle with fluorescent light. I once read that fluorescent light is bad for Vit D levels (???) Of course, I HATE Fluorescent light because I am a photographer and it makes people look greenish and ugly, and all the white balance controls in the world can't really compensate...

    I have the sunroof in the car open to and from work, and walk outdoors during my lunch hour and before and after work when sun is out. To no avail. But the sun does at least make me happy. I'm a huge believer in sun as mood enhancer, so skin cancer be damned. And I am forever preaching to people about avoiding sunblock as it blocks Vitamin D synthesis in the skin (this may be a factor in studies where they say that light exposure did not change Vitamin D levels, given the number of products that now contain sun block??)

    In addition, modern Western ideas of cleanliness interfere with the Vit D absorption cycle from being in the sun (I think): I've read that if one bathes after being in the sun, and washes off skin oils before they are absorbed, one loses the Vit D precursors?? I don't have the studies, but they looked at street urchins and over-washed suburban brats, and the poor kids had better levels...

    Last, but not least, I've been pondering for a while (and you would know better than I where to explore this) whether the whole debate about Vit D levels and disease isn't going at it the wrong way. Perhaps low Vit D levels don't cause disease. Perhaps the low Vit D levels are actually the sign of some process already under way that is damaging Vit D absorption. In other words, there is already adequate exposure or intake, but some malabsorption or damage has already happened. And THAT is what leads to cancer/depression/heart disease (or is a common marker for their beginnings). Excuse scrawled wacky theory, but you could tease out if it's BS or not..:)

    I've found that even megadoses (small daily, and once a big huge ones) don't seem to make a real difference.

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  6. "Standing on the Sun Will Not Prevent Depression"

    Yes, it will.

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  7. There seems to be a lot of criticism if my silly metaphor. Give me the benefit of the doubt and assume an extremely short timeframe, if you must be literal.

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  8. Some of us got it Emily ;)

    One thing that I wanted to add was a study (which I'll have to track down again) that showed a higher turn over of vitamin D with the consumption of wheat. So just throwing it out there - is low vitamin D a marker for wheat consumption as well as low UVB exposure?

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  9. Standing on the sun only permeated my brain on second reading but it certainly gave me a giggle. I have to go with curiousapc. It would be on a par with skydiving without a parachute for the 100% protection against cancer mortality.

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  10. I think in future all cultural references should be properly footnoted.

    Thanks.

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  11. Oh, for heaven's sake. I realize that medical science and literary devices often make for an awkward mix. See "Beauty and the beast: B12, homocysteine, and the brain, a bemusing saga!" (http://www.ncbi.nlm.nih.gov/pubmed/20956785). But that was a neurologist! Psychiatrists work in metaphor. "Standing on the sun" = "Half a million IU D3 in one go is a really %^&$ing bad idea." As for the actual physics of a literary device - think of le petit prince on that charming asteroid. Could that little rock possibly have an atmosphere or an appreciable gravitational field? Would he not fly off into the cold dark of space, dying a horrible death of suffocation and liquid body parts boiling away? Of course he would!

    Open your hearts to a touch of magical realism. You don't have to like Gabriel Garcia Marquez or anything.

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  12. Dr. Deans, I really enjoyed the title. It brought me a smile, which I find at least as important as my food plan and supplements.

    I so appreciate your kind ways of bringing beauty and good cheer in your posts of science and common sense.

    It is a great joy to read posts and comments of those who know how to combine kindness, thinking, and art, with the cheer of loving life.

    Thank you. :)

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  13. Dr. Deans,

    Why won't you supplement next fall/winter? I feel like even traditional HG populations who live at northern latitudes (the Inuit come to mind) consume fish and seal that probably contain some level of vitamin D. Cod liver oil in the winter, perhaps?

    Thanks for all the writing you do!

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  14. Very interesting.

    N=1 , but I have a mood disorder (been told by three different professionals I have diagnoses including "some kind of bipolar", bipolar II, and being a sensitive flower.)
    I'm fairly introspective and not that dumb, so I tend to think I have depression with a hint of bipolar. Like, cyclothymia but worse, or bipolar II but not as serious.

    I clearly have a strong seasonal effect to my moods.

    I've used vitamin D3 for mood, and I"ve used light therapy. Hands down, no questions asked, light therapy is by *far* superior.

    I went from a terrible, moderate to severe depression 2 years ago, to a mild depression, within one week. My depression was worsening, and worsening, week after week, starting in october and up until the end of november. If it had gotten any worse I don't know what would have happened. At the worst of it I was crying daily, and thinking of suicide. On days off of work I could hardly get out of bed, I did not get dressed or leave my house except maybe to obtain coffee (the bleak ray in my existence at that time: coffee made me feel less abjectly horrible). It was so extremely painful and debilitating. My whole body ached. My arms felt heavy, I could barely move them. My head had cotton batting. Turning my head even would hurt and the visual/mental effort required of SEEING would exhaust me.

    You get the idea.

    Well, I started light therapy, because I had an epiphany that my moods are very seasonal.

    The first time I ever had "Manic" symptoms I was 23 and it was july, and seemed a direct reaction of sleep deprivation plus excessive light. I spent that week out in the sun doing things, and I stayed up all night.

    The second time I had another problem with "manic" symptoms I was 25 and it was june, and again we see it starting in the warm bright months.

    This depression at 27 started in october, a direct reaction to the decreasing light and decreasing temp (among other things).

    SO, like, duh, light.

    And I was right.

    Within a day of using the light, I felt shot full of energy in my body. I still was miserable and depressed but all of a sudden, by the end of that day, I had ENERGY for the first time in weeks. I could easily take a shower, and I vividly remember that, because it was the first time in weeks I could do anything physically without requiring superhuman effort.

    Within a week of using the light almost all the depression was gone, although I still had mild depression (the "usual" kind of depressions I get, of a mild-moderate intensity where my functioning is not that badly impaired and it is just internal pain and suffering).

    I started developing manic symptoms shortly after the light therapy. At first it was manifested as intense anger and irritation. I would want to break things and have ridiculous feeling of energy shooting out of my arms. I was still depressed at this time, but I also had overwhelming energy.

    By the end of the month all the depression was absolutely gone, however I had manic type issues now and I felt fantabulousastic and was prone to looking cracked out at times, not sleeping much, and spending heaps of cash. That ran a natural course and within 2 or 3 weeks I was back down to the ground as if it never happened.




    This experience taught me a valuable lesson.
    Light therapy is SUPER DUPER important.


    I have been using vitamin d for... months, years? Ive increased the dose, I've decreased the dose. I have never, ever, observed an effect on mood, other than what could easily be placebo. Light on the other hand is like a super strong drug for me. It's no joke and I am so grateful I found it because without it I would have looooads more depression.

    To be honest I have a hard time even understanding the vitamin D enthusiasm. It has never helped me, in fact I notice I seem to have immune system suppression when I take too much. I can't explain it but I always get more colds and viruses and have trouble fighting them off if I take too much vitamin D3.

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  15. David Moss makes a good point.

    Sun exposure has way more benefits than vitamin D. Is it the light? Is it the vitamin D synthesis? My personal experience as a slightly crazy person leads me to believe light >>> vitamin d. Sun increases testosterone in men why? Answer: light suppresses melatonin, increases LH and FSH and so wham fertility (in men this = more testosterone production and in women better more regular ovulation and higher estrogen).
    Light is almost an essential nutrient, but people go around indoors, in offices, like it's not. It would be naive to think that the explosion in mild / moderate depression has nothing to do with the abnormal, totally pathological lack of sunlight (among other factors), especially considering there is evidence light is a major regulator of neurotransmitters and hormones.
    Saying that the sun won't prevent depression, simply because stupid vitamin D is useless, is not founded, because some evidence suggests light is like medication for many kinds of depression; not just SAD but bipolar and unipolar and all sorts of depression.

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  16. ItsTheWoo - Light has a very separate, powerful, and immediate effect separate from Vitamin D, absolutely, tons of papers, even a research website called Chronotherapeutics I believe. I blogged about that under "Chronotherapeutics for affective disorders" a while back with some interesting links. I never suggested that the sun in proper physiologic doses won't prevent depression. In fact there is a large body of evidence that it does. Massive massive vitamin D in one go will not.

    Everyone - I haven't mentioned this before, but one of the reasons I am wary of large *oral* doses of vitamin D long term (and by large I mean even more physiologically reasonable doses, such as 6000 IU daily) is an interesting thing I read in one of those online posts by Stephanie Senoff at MIT - who always has really fascinating, thoughtful stuff, though I don't agree with all of it, I could certainly be the one in the wrong on those disagreements. (Here's a link to one of her articles but I'm not sure if it is the article I was reading before http://people.csail.mit.edu/seneff/swine_flu_obesity_vitamin_D.html ).

    She made an interesting point (and I have no idea how substantiated it is and I haven't looked it up) that vitamin D is antibiotic - do we really want to have constant bombardment of our gut flora with large amounts of oral vitamin D? Seal fat and cod liver oil gives milk fortification-like doses of a few hundred IU, not many thousands. I have no idea as to the reasonableness of this assertion, but it seems like a good question to be answered. So I fall back to the evolutionary failsafe - recognizing that if one is found to be horribly deficient in northern hemisphere September, the benefits might outweigh the risks of large oral supplementation to get you topped off. But otherwise, fair to say we should get maybe 10% through the gut and 90% through the skin if we can manage.

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  17. (I'm fully willing to admit I used the metaphor sloppily in the title, but now I'm just being stubborn in leaving it there)

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  18. ITW, thanks very much for your comments. I always appreciate the things you emphasize and describe, and find them most useful.

    Dr. Deans, the point about antibiotics and gut flora is certainly something to consider. Thank you for writing that. And thank you for the 10/90 proportion guideline.

    I quite enjoyed the sun title, and am grateful for your creativity in writing the blog posts. :)

    Looks as though bundling up and braving the cold more often in the winter to get some sunshine, and looking into a fancy light is key.

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  19. I for one really liked the metaphor.

    Perhaps strangely I've always experienced an immediate positive effect from Vitamin D supplement megadoses (around 15000 iu), although not more so than just standing in the sun.

    I've found in my own personal experience that vitamin D tends to help with the pain associated with depression - if not the depression itself. I don't come away from a dose thinking more positively about life, but I am less psychologically pain ridden.

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  20. the Marshall Protocol is very interesting. They see that many with low vit 25 (OH) Vitamin D3 levels, have very high 1,25 OH Vitamin (the active hormone, )wich they mean/think is an sign that the immunosystem has a lot of intracellular microorganisms.
    Molecular research shows that 25(OH) D3 acts similar like a corticosteroid, and like prednisolone it will in big doses make your feel great, but in the long run be not so great.
    http://mpkb.org/
    Anyone that has tride to look at this protocol?

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  21. sorry I didnt mean corticosteroid, but steriodhormone sorry.

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  22. If you have a problem standing on the Sun and getting too much D, go at night:)

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  23. A question that arises from all of this. Given the alleged links of D3, Magnesium, Omega 3, etc. to depression, what blood tests would you recommend for a woman with depression to see if the condition could result/be exacerbated by a vitamin/mineral deficiency.

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  24. Standard tests for depression would include folate, vit B12, CBC, thyroid studies, and I measure 25 OH vit D3 though that is not standard, simply because I find so many low ones. Sometimes I will run a ferritin too if sleep is poor.

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  25. A very basic question: why is a lower blood level recommended for those with dark skin? I assumed that dark skin was an adaptation to year-round exposure to intense sunlight--meaning that people with dark skin would have had more opportunities to generate vitamin D.

    On the other hand, I'm aware that dark-skinned people are more likely to be deficient since their bodies produce less D on contact with sunlight. Does this lower rate of production bring their levels down below the levels of white-skinned people? Or am I completely off the mark with this?

    There are other factors as well... in the very sunny place my family comes from, people wear light clothes that cover their entire bodies... I assume it's to avoid excessive sunlight.

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  26. Hi Asad - I'm relying to some extent on Paul Jaminet's writings, but also some of the studies I've read suggest that high vitamin D levels in pregnancy are helpful in caucasian women but made no difference in women with darker skin. Also, it is far more likely that white skin is a result of sexual selection than vitamin D selection. So...

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  27. Emily,

    After writing on depression for over a year, could you do a summary post of advice you'd give to someone who thought they were depressed?

    I see you discussing inflammation, diet, exercise, micronutriet status, thyroid status, etc, but it would be super helpful to have it all in one place to be able to refer to.

    Thanks,

    Ed

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