title: Latitude, sun exposure and vitamin D supplementation: associations with quality of life and disease outcomes in a large international cohort of people with multiple sclerosis.
abstract: BACKGROUND
  A growing evidence base implicates vitamin D, sun exposure and latitude in the aetiology of multiple sclerosis (MS), however there are less data on the associations of these variables with disease outcomes.
  
  
  METHODS
  We undertook a cross-sectional survey of over 2000 people with MS recruited through internet platforms, seeking self-reported data on geographical location, intentional sun exposure for health, and supplementation with vitamin D, among other lifestyle variables. We also requested data on health-related quality of life (MSQOL-54), self-reported doctor-diagnosed relapse rate, and disability (Patient Determined Disease Steps). Bivariate and multivariate analyses were used for comparisons, including multiple linear regression modeling.
  
  
  RESULTS
  Of 2301 participants, 82.3 % were female, median age was 45 years (IQR 38-53 years), with a median time since diagnosis of 6 years (IQR 3-12 years), the majority (61.6 %) having relapsing-remitting MS. Nearly two-thirds (64.6 %) lived in the Northern hemisphere, mostly in developed countries. Most (66.8 %) reported deliberate sun exposure to raise their vitamin D level, and the vast majority (81.8 %) took vitamin D supplements, mostly 2000-5000 IU a day on average. Unadjusted regression modeling incorporating deliberate sun exposure, latitude and vitamin D supplementation showed strong associations of sun exposure with HRQOL which disappeared when controlling for gender, age, disability, physical activity, and fish consumption. In contrast, associations between vitamin D supplementation and HRQOL were maintained adjusting for these variables, with a dose-response effect. Only latitude had significant adjusted associations with disability, with an increase of latitude by one degree (further from the equator) predicting increased odds of moderate disability (OR 1.02 (95 % CI 1.01-1.04)) or high disability (OR 1.03 (95 % CI 1.01-1.05)) compared to no/mild disability. Similarly, latitude was related to relapse rate, with increase in latitude of 1 degree associated with increased odds of having more relapses over the previous year (1.01 (1.00-1.02)).
  
  
  CONCLUSIONS
  We detected significant associations between latitude, deliberate sun exposure and vitamin D supplementation and health outcomes of this large group of people with MS. Vitamin D is likely to have a key role in these associations and its role in the health outcomes of people with MS urgently requires further study.
authors.affiliation: Neuroepidemiology Unit, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia. g.jelinek@unimelb.edu.au.
authors.forename: George A
authors.initials: GA
authors.lastname: Jelinek
authors.affiliation: Neuroepidemiology Unit, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia. Claudia.Marck@unimelb.edu.au.
authors.forename: Claudia H
authors.initials: CH
authors.lastname: Marck
authors.affiliation: Neuroepidemiology Unit, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia. Tracey.weiland@svha.org.au.|Emergency Practice Innovation Centre, St Vincent's Hospital, Melbourne, VIC, Australia. Tracey.weiland@svha.org.au.
authors.forename: Tracey J
authors.initials: TJ
authors.lastname: Weiland
authors.affiliation: Emergency Department, Box Hill Hospital, Box Hill, VIC, Australia. Naresh.pereira@gmail.com.
authors.forename: Naresh
authors.initials: N
authors.lastname: Pereira
authors.affiliation: Emergency Practice Innovation Centre, St Vincent's Hospital, Melbourne, VIC, Australia. Daniavan8@gmail.com.
authors.forename: Dania M
authors.initials: DM
authors.lastname: van der Meer
authors.affiliation: Neuroepidemiology Unit, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia. Emily.hadgkiss@unimelb.edu.au.
authors.forename: Emily J
authors.initials: EJ
authors.lastname: Hadgkiss
mesh_terms: D000203:Activities of Daily Living; D000328:Adult; D015331:Cohort Studies; D003430:Cross-Sectional Studies; D019587:Dietary Supplements; D005260:Female; D005843:Geography; D006304:Health Status; D006801:Humans; D008019:Life Style; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D009103:Multiple Sclerosis / Q000503:physiopathology; D020529:Multiple Sclerosis, Relapsing-Remitting / Q000503:physiopathology*; D065840:Protective Factors; D011788:Quality of Life; D012008:Recurrence; D012307:Risk Factors; D012720:Severity of Illness Index; D013472:Sunlight; D014807:Vitamin D / Q000627:therapeutic use*; D014815:Vitamins / Q000627:therapeutic use*
chemical_list: D014815:Vitamins; D014807:Vitamin D