Scotland Vit D

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G Scots have lower levels of vitamin D than English people. Healthy people get more than 90
per cent of their vitamin D from exposure of their skin to sun. But Scotland receives less sun-
light, has a shorter summer season and colder weather than England, which accounts for the
lower vitamin D levels in the population.
G Insufficient vitamin D is an important factor increasing the risk or severity of several
chronic diseases including cancer, heart disease, multiple sclerosis, high blood pressure,
stroke, diabetes and arthritis as well as bone disease and fractures.
G A higher incidence of chronic disease and higher premature mortality in Scotland, compared
with England and other European countries, is only partly explained by known risk factors such
as smoking, alcohol, diet or poverty. Lower average levels of vitamin D in Scotland can explain
the additional deficit.
G Successive reports on the state of Scottish health have failed to recognise that insufficient
sunlight and vitamin D are important risk factors for health in Scotland.
G Provision of vitamin D supplements, fortification of food with vitamin D, and revised ad-
vice on sun exposure may be expected to secure substantial health gains in Scotland at lit-
tle cost.
G Firm action is required by Scotland’s government to implement such measures: to make suit-
able vitamin D supplements available and to promote their use for all, to investigate and pi-
lot the most effective ways of fortifying food with vitamin D, and to facilitate new advice on
sun exposure based on broad multi-disciplinary considerations.
HealthRese
arch Forum
Oliver Gillie
Health Research Forum Occasional Reports: No 3
SCOTLAND’S
HEALTH
DEFICIT: AN
EXPLANATION
AND A PLAN
SCOTLAND’S
HEALTH
DEFICIT: AN
EXPLANATION
AND A PLAN

SCOTLAND’S
HEALTH
DEFICIT: AN
EXPLANATION
AND A PLAN
HealthRese
arch Forum
Oliver Gillie
Scotland has an extreme climate characterised by very little sunshine. Its people have low
levels of vitamin D because most vitamin D comes from the effect of sun on skin. Scots also
have high levels of chronic illness – among the highest in the world. Low levels of vitamin D are
now known to be an important cause of chronic illness including cancer and heart disease. But
vitamin D has received little or no attention from policy makers in Scotland.

Health Research Forum Occasional Reports: No 3 III
Scotland’s health deficit – an explanation and a plan
is highly recommended by international experts. This is what they said:
“This impressive piece of work has major significance for Scotland’s health. Dr Gillie’s
meticulous research and careful argument call for serious attention from its policy makers.”
Professor Joy Townsend, London School of Hygiene and Tropical Medicine
“Oliver Gillie makes a very compelling case that widespread vitamin D deficiency contributes
importantly to the many health problems that plague Scotland.”
Edward Giovannucci, Professor of Nutrition and Epidemiology, Department of Nutrition,
Harvard School of Public Health
“A collaboration of researchers in Scotland have been inspired to think again about the
potential role of vitamin D in improving Scotland’s health. It is a privilege to be working with Dr
Oliver Gillie who has a long-standing interest in Scotland, its people and vitamin D, as is clear from
a reading of this book.”
Dr Raj Bhopal, Bruce and John Usher Professor of Public Health, University of Edinburgh
“I found your book very interesting. I grew up in Scotland, and I often recall my mother, on rare
sunny days, exhorting me to go out and ’soak up the sun’, as it was good for me. I’m sure she was
passing on an ’old wives’ remedy with real substance. I really think we need to find a way to undo
the short-sightedness of the broad public health campaigns that try to stop entire populations
from being out in the sun ’unprotected’.”
Dr Colin Begg, Memorial Sloan-Kettering Cancer Centre, New York
“The UK has it bad, but Scotland has it even worse when it comes to a lack of sunshine. It is all
too easy to be sceptical that a technology so simple as vitamin D could play a major role in
correcting a breadth of health deficits. Oliver Gillie has laid out out the problems and the
solutions so logically that only the most incurable sceptic could remain unswayed.”
Dr Reinhold Vieth, Professor, Department of Nutritional Sciences, University of Toronto
“Gillie has collated a large body of data from different diseases and makes a strong case for the
role of vitamin D deficiency in the pathogenesis of a variety of disorders ranging from heart disease
to autoimmunity. There is no source that covers this so comprehensively and after reading this
monograph more questions will and should be asked about the public policies that have continued
the same practices now for half a century. There are additional scientific questions to be sure, but
continued inaction at a public health level warrants urgent review. Gillie has performed an
extremely important service in tirelessly promoting the ideas in this book and he has many strong
scientific supporters. I include myself among these, and the evidence suggests that at least some of
the diseases he reviews will have vitamin D as their basis. At the very least we need an urgent
policy rethink and need to ensure that the status quo is not inertial in nature.”
George Ebers, Action Research Professor of Clinical Neurology, Oxford University, England
I Scotland’s health deficit: An explanation and a plan
Scotland’s health deficit: An explanation and a plan I
Published by Health Research Forum, 68 Whitehall Park, London N19 3TN
email: olivergillie@blueyonder.co.uk phone: +4420 7561 9677
First edition 2008
Health Research Forum Publishing
All rights reserved.
Health Research Forum is a private non-profit making research organisation founded by Oliver Gillie in 2004.
ISBN numbers: 9553200-2-X and 978-0-9553200-2-6
Disclosure
Oliver Gillie has received no personal remuneration from commercial interests that might profit from any
aspect of this work. In particular he has never accepted personal payments from makers of sunlamps or
vitamin supplements, or their proxies.
Key words:
Scotland, Scottish effect, mortality, chronic disease, vitamin D, deficiency, sunlight, sunlamps, sunbeds,
tanning, UVB, climate, cancer, heart disease, heart failure, hypertension, blood pressure, stroke, bone disease,
rickets, osteomalacia, osteoporosis, multiple sclerosis, diabetes, Crohn’s disease, rheumatoid arthritis, asthma,
autoimmune disease, chest infection, tuberculosis, back pain, muscle strength, sport, fitness, stress fracture,
tooth decay, public health, health policy, SunSmart, Cancer Research UK, sunbathing, melanoma, skin cancer,
nutrition, breast feeding, Orkney, Shetland, Faroes, Iceland, multiple sclerosis epidemic, childhood leukaemia
(leukemia) epidemic, fish diet, Sir Richard Doll, James Watson.
Contact: Oliver Gillie, 68 Whitehall Park, London N19 3TN
email: olivergillie@blueyonder.co.uk phone: +4420 7561 9677
Design and production: Design Unlimited
Editing and sub-editing: Jim Anderson and Michael Crozier

Health Research Forum Occasional Reports: No 3 V
In remembrance of my father John Calder Gillie, nautical instrument
maker, optician, and Quaker philanthropist
For my wife, Jan Thompson, and my two sons, Calder and Sholto, who
have encouraged me to continue with this project
“Nearly a century ago it became obvious that vitamin D can cure rickets in infants, an illness
also known as English disease. Oliver Gillie shows us that vitamin D deficiency is still frequent in
the adult English population and is even more frequent in Scots. This situation presumably
contributes to many chronic diseases. Hopefully, the present book opens the eyes of many health
authorities that a century after vitamin D’s discovery its deficiency has not been erased yet.”
Dr Armin Zittermann, Department of Cardio-Thoracic Surgery, Ruhr University Bochum,
Bad Oeynhausen, Germany
“I visited Scotland in 2004 at the request of Dr George Ebers to discuss the role of vitamin D
and multiple sclerosis with Scottish neurologists. I returned for a holiday three years later, went
into a chemist and found that vitamin tablets still contained only 200 IU of vitamin D, a woeful
amount. Hopefully this wonderful piece of work by Dr Gillie will change the status quo.”
Dr Bruce W. Hollis, Professor, Medical University of South Carolina, Charleston,
South Carolina
“Oliver Gillie has an established track record in the presentation of scientific material in an
informative and balanced way and is exceptionally well informed about vitamin D. His report on
the ’Scottish paradox’ details evidence suggesting that simple measures to correct lack of vitamin
D, so common in Scotland, would contribute substantially to reducing the burden of chronic
disorders such as diabetes and heart disease.
“I have vivid memories of my childhood in Troon where herrings, cabbage, oatmeal and cod
liver oil were common in our diet. Now many years later I am grateful for good health that
probably owes something to those nourishing staples, despite little enough sunshine in those early
years.
“I am in no doubt that the bodies concerned with public health in Scotland will find this report
useful in devising cost-effective measures for avoiding hypovitaminosis D and thereby reducing the
burden of chronic disease on the Scottish people, on the health service and the national budget.”
Dr Barbara Boucher, honorary senior lecturer, Centre for Diabetes and Metabolic
Medicine, Barts and the London Medical and Dental School, London
“Dr Gillie’s book is both timely and enlightening. There is a mountain of new scientific literature
that supports the concept that vitamin D deficiency may be responsible for increased risk of many
chronic diseases including cancer, heart disease, diabetes and infectious diseases. Vitamin D
deficiency has become a world-wide health problem and is very evident in Scotland. Dr. Gillie
provides a lucid review of the evidence linking chronic vitamin D deficiency to many health
problems that particularly plague the Scots. Sensible sun exposure, that is when the sun is shining
in Scotland, along with a very aggressive program to implement vitamin D food fortification is
greatly needed, and the recommendations made by Dr Gillie are insightful and should be
implemented immediately.”
Dr Michael Holick, Department of Medicine, Boston University Medical Center,
Boston, USA
IV Health Research Forum Occasional Reports: No 3
Scotland’s health deficit: An explanation and a plan I I Scotland’s health deficit: An explanation and a plan

Health Research Forum Occasional Reports: No 3 VII
Summary
Introduction: Scotland’s health deficit
Chapter 1: The “sunshine vitamin” and the Scots’ climate
1. Scotland gets less sun – Scots less D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
2. Eskimos, Lapps – and Scots . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
3. Remarkable list of D diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
4. The ‘Scottish effect’ – an explanation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
5. An early death in Scotland: Mortality studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Chapter 2: Scotland’s major killers
1. Heart and blood vessel disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
2. Blood pressure and stroke – the quiet killers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
3. Heart failure – vitamin D can help . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
4. Heart failure in infants – tip of an iceberg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
5. Cancer – increased risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
Chapter 3: Scotland’s bane: the epidemic of immune system diseases
1. The silent epidemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
2. The Big Four autoimmune diseases:
2.1. Multiple sclerosis – a world record for Scotland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
2.2. Diabetes in young people (type 1)– a British record for Scotland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
Diabetes in older people (type 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
2.3. Rheumatoid Arthritis – a northern affliction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
2.4. Inflammatory bowel disease – unspoken suffering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25
3. Asthma and other chest conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
Chapter 4: Bone disease, muscle disease and sport
1. Rickets and fractures in childhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
2. Bone disease and adult fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31
3. Dental decay – more to it than fluoride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33
4. Unexplained backache and muscle pains . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35
5. Muscle weakness and depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
6. Sport – is Scotland achieving its potential? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
7. Sport – stress fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38
Chapter 5: Winter illness and other infections – need we suffer so much flu and so many colds?
1. Dramatic effect of D on immune system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40
2. Tuberculosis: more common in spring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40
3. D stimulates production of antimicrobial peptides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41
Chapter 6: Epidemics on the north Atlantic islands
1. Wartime “epidemics” of multiple sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42
2. An epidemic of leukaemia – troops blamed again . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43
3. Prescription – fish twice a day with meals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44
4. Wartime rationing – one egg every two months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46
5. Two diseases with something in common . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47
6. Leukaemia – an event in pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48
7. Cancer and Crohn’s in the north Atlantic islands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49
ContentsAcknowledgements and thanks
I could never have undertaken this work without the help of very many people who have freely discussed their re-
search with me and taken the trouble to explain details to me. I am greatly indebted to them for their unstinting
help.
To the best of my knowledge the hypothesis advanced here, that the deficit in health of Scots compared with
English people and other Europeans can be accounted for by low sunlight levels and insufficient vitamin D, has not
been stated explicitly before, or not in any detail. However this hypothesis and the conclusions in this book rest
on the work of very many others who have shown the way with their studies of Scottish health, vitamin D and sun-
light. Without their patient and painstaking research over many years this hypothesis could not have been devel-
oped.
In particular the works of Phil Hanlon and colleagues on the “Scottish effect”, and of Richard Mitchell and col-
leagues on unexplained high levels of heart disease in Scotland deserve great credit for identifying the problem. While
the work of RW Morris, PH Whincup, and AG Shaper and others at the British Regional Heart Survey on the geographic
variation in heart disease in Britain has also been very important. Jonathan Elford and colleagues’ studies of place
of birth and migration in connection with heart disease have provided further important insights. These studies and
many others credited within have been most important in developing an understanding of health in Scotland, of
the “Scottish effect” and of vitamin D insufficiency.
I also wish to acknowledge the dedicated pioneering work of many scientists over many years to demonstrate
the vital role of vitamin D in human life. Among these pioneers I must mention Reinhold Vieth, Michael Holick, Bill
Grant, Bruce Hollis, Robert Heaney, John Cannell, the Garland brothers and their colleagues, George Ebers and col-
leagues, Barbara Boucher, Elina Hypponen, Adrian Martineau and many others. Any list of this kind does an injus-
tice to others by leaving them out. Please allow me to thank all those whose important work is mentioned in the
text but whose names are not mentioned here.
Finally I am also specially grateful to my wife and family who have encouraged and supported me in undertak-
ing this work, to Michael Crozier and Jim Anderson for their practical help and encouragement, to Joy Townsend for
her detailed comments and guidance, and to Julian Peto for his friendship and wisdom.
Oliver Gillie
April 2008
VI Health Research Forum Occasional Reports: No 3

Health Research Forum Occasional Reports: No 3 1
Summary
People living in Scotland have a lower average level of vitamin D in their bodies than people in England and a
higher incidence of several common chronic diseases. The difference in vitamin D levels is a result of Scotland’s
northerly location, which allows less opportunity for exposure of the skin to sunlight. A healthy person in Europe
or North America obtains more than 90% of their vitamin D by exposure of skin to the sun. The low levels of
vitamin D in the Scottish population can explain, at least in part, the higher levels of certain chronic diseases and
the higher death rates found in Scotland compared to England and most other Western European countries.
While health has been improving in Scotland, the advance is not as fast as in other European countries, and at
the present rate Scotland will never catch up. This report calls for urgent action by Scotland’s government to take
new measures that will give the country its best chance of improving health and of catching up with other
European countries that have more favourable climates.
Insufficient vitamin D is an important factor increasing the risk or severity of several chronic diseases including
several cancers, heart disease, stroke, multiple sclerosis, high blood pressure, diabetes (types 1 and 2), and arthritis
as well as bone disease and fractures that frequently lead to death in old people. Most of these, and certain
other ills, occur more frequently in Scotland compared with England – a difference that may be accounted for large-
ly by the difference in available sunlight between the two countries. Looking at multiple sclerosis alone, Scotland
has a higher percentage of sufferers than any other country in the world, and the second highest percentage for Crohn’s
disease.
However successive reports on the state of Scottish health have failed to recognise that insufficient sunlight and
vitamin D are important risk factors for health in Scotland. The purpose of this book is to draw attention to this gap
and show how major gains in Scottish health can be expected from relatively simple preventive measures.
Multiple sclerosis, diabetes type 1, and Crohn’s disease are autoimmune diseases which have become much more
common in Scotland during the last 30 years or more. It is no exaggeration to say that Scotland is in the grip of a
serious epidemic of autoimmune disease. Similar increases are occurring in other countries but the epidemic
appears to be more extensive in Scotland than elsewhere and may be caused in large part by insufficient vitamin
D.
The vitamin D status of the Scottish population could be boosted by making supplements available cheaply and/or
by fortifying food with vitamin D. A relatively small investment might reduce personal misery of very large
numbers of people as well as save large sums presently spent on illness and disability in Scotland. The problem of
vitamin D insufficiency requires the same urgent attention from government as smoking, alcoholism or obesity.
Vitamin D status can be improved without the personal denial or discipline needed by smokers, drinkers, or
dieters who attempt to give up cigarettes, or reduce alcohol or food intake. The principal factor preventing
improvement in vitamin D levels at present is lack of government action in facilitating the availability of vitamin D
supplements together with lack of knowledge of the problem among health professionals and the public.
Mistaken advice from government in London and from Cancer Research UK to avoid exposure to the sun between
11am and 3pm can only have pushed down average levels of vitamin D in the past. Official advice needs to be brought
up to date so that the public is encouraged to sunbathe without burning, since burning appears to be the major risk
factor for skin cancer rather than sun exposure itself.
Chapter 7: A new Public Health Policy for sunlight and vitamin D
1. Full review not undertaken by government advisors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50
2. UK government now recommends sunshine – and bare shoulders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50
3. Risks v. benefits of sun exposure: 2,000:1 in favour of exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52
4. Westminster bungles supply of infant vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53
5. Canadians advised to take a supplement – why not Scots? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54
Chapter 8: Advice for individuals
1. Supplements – easy and reliable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55
2. Sunbathing – the SunSafe advice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56
3. SunSmart’s mistakes – Britons told to play by Australian rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57
4. Vitamin D protects skin cells . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59
5. Sun lamps and sun beds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60
Chapter 9: Towards a “step-change” in Scots’ health
A check list of action needed from the Scottish Government . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62
Chapter 10: Sir Richard Doll and vitamin D
1. Influence of a non-significant trend . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64
2. Courageous change of mind . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64
3. James Watson, DNA and vitamin D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65
Chapter 11: Finding the trail – how this began
1. Sunlight Robbery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66
2. Scotland – a personal note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67
Chapter 12. For the record
1. Health Research Forum: report of activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69
2. A note on methodology: investigative review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71
3. A brief biography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91
VIII Health Research Forum Occasional Reports: No 3

Health Research Forum Occasional Reports: No 3 32 Health Research Forum Occasional Reports: No 3
en together they show a remarkable overall improvement in mortality of those taking a vitamin D supplement.
Another study (double blind and randomised) found that 55-year-old women in Nebraska who were given a daily
dose of 1100 IUs of vitamin D over a period of four years were half as likely to suffer cancer as control women
given a placebo [11].
Many reasons – smoking, alcoholism, and poverty – have been considered as explanations of the excess ill health
and mortality in Scotland [1]. But until now, insufficient vitamin D has not been considered as a possible explana-
tion. Numerous reports on Scottish Health refer to problems of smoking, obesity and alcohol but make no
mention of vitamin D or of the problems from too little sunshine in the Scottish climate [2, 12-17].
Health Protection Scotland, the body which is charged by the Scottish Executive with the task of strengthen-
ing and co-ordinating health protection north of the border makes no mention of vitamin D on its website although
detailed information about other risk factors for disease are listed [18]. And at the time of writing the Scottish
Public Health Observatory, which has a similar brief, makes no mention of vitamin D insufficiency as a risk factor for
cancer, heart disease, or multiple sclerosis and does not even mention rickets, the childhood bone disease that is
re-emerging in Scotland as a result of insufficient vitamin D [8, 19].
It is only in the last 10 years or so that the many functions of vitamin D essential for health, besides the regula-
tion of calcium absorption and the growth of bone, have become known and knowledge of its importance for health
is only now reaching specialists in public health [20]. Practising doctors and even nutritionists have not generally
been aware of these developments until very recently. However, internationally recognised experts now
acknowledge that insufficient vitamin D is a major risk factor for chronic disease comparable in importance to
smoking, alcohol or obesity [20].
This review explains the relevance of new findings concerning vitamin D to the health of people in Scotland and
outlines a plan to produce a “step-change” in Scottish health. Much political attention has been given to health
inequalities within both Scotland and England [21]. The health inequalities between our two nations deserve
equally urgent attention and urgent political action.
Introduction:
Scotland’s health deficit
Scotland is bottom of the premier league of nations when it comes to health [1]. People in Scotland die younger
on average than in almost any other Western European nation of similar stature – see figure 1 below [1]. Premature
mortality in Scotland’s central belt reaching from Glasgow to Edinburgh is close to that of the former East Germany
(German Democratic Republic) and is the highest in Europe [2]. This position has puzzled scientists for at least a
generation. In this review I offer an explanation of the Scottish health deficit and suggest how major gains in health
could be obtained in Scotland by relatively simple measures.
Figure 1. Comparison of all-cause mortality rates per 100,000 population (age-standardised) for males and
females. Mortality of Scots females is even higher in this international league than that of Scots males.
Source: WHO.
Scotland’s geographical position on the edge of the Atlantic and in the most northern part of Europe gives it a
cloudy maritime climate with much reduced hours of sunshine compared with other northern countries of
continental Europe or with southern parts of the UK. Glasgow, because of its position on the western seacoast, gets
no more sun than places above the Arctic Circle. As a result Scots people obtain much less exposure to the sun [3]
and so obtain insufficient vitamin D [4-7], compared with people in England and most other European countries –
see Figures 2-4. Many scientific studies have found that low levels of vitamin D are associated with higher
mortality from cancer, heart disease, raised blood pressure, stroke, diabetes and other diseases [8, 9] which account
for up to 70% of total mortality in Scotland and other industrial countries.
The suggestion made here that excess mortality in Scotland is the result of insufficient vitamin D is bolstered
by international studies showing that people who take a vitamin D supplement live longer and are less likely to die
early from cancer, heart disease or other ills [10]. Taking a regular supplement of vitamin D may reduce overall
mortality by 7% or more according to a recent analysis of pooled results of international trials of vitamin D [10]. Most
of these trials were originally undertaken to study prevention of osteoporosis, fractures or other conditions but tak-
Figure 2. Seasonal and geographical variation in the prevalence of hypovitaminosis D (25-hydroxyvitamin D
less than 40 nmol/L) in Great Britain. Low levels of vitamin D are particularly obvious in Scotland in
summer and autumn. From Hypponen and Power [5].

I Scotland’s health deficit: An explanation and a planScotland’s health deficit: An explanation and a plan I
Chapter 1:
The “sunshine vitamin” and the Scots’ climate
1. Scotland gets less sun, Scots get less D
The major population concentrations in southern England and central Scotland are only some 300 miles apart on
a north-south axis. London is at latitude 51.5° north while Glasgow and Edinburgh are at 56° north. But this smal
difference in distance makes a large difference to the amount of “biologically active” UV light that reaches earth
and is capable of inducing the formation of vitamin D in skin.
Even in Scotland sunlight remains the major source of vitamin D. But it is only certain wavelengths of UV that
induce formation of vitamin D in skin while other wavelengths are inactive. The active part of the UV spectrum lies
in the range known as UVB and it is absorbed more readily in the atmosphere than other wavelengths. So when the
sun is low in the sky and the light travels through a longer path in the atmosphere the active UVB component of
sunlight is reduced, and when the angle of the sun is below about 45° active UVB is almost completely absent from
sunlight.
Scotland receives some 30-50% less biological active UVB than much of England (see Figure 3 [3, 22]). The sun
north of the border is lower in the sky for most of the year and so more of the active UVB is absorbed in the
atmosphere than at lower latitudes. A definitive geographical comparison of “effective UVB”, that is UVB weighted
for its biological effect in reddening skin, has been made by Colin Driscoll of the National Radiological Protection
Board at Chilton in Oxfordshire and others [23]. UVB that reddens the skin is often taken as much the same
wavelength as the UVB that is most effective in synthesising vitamin D.
Figure 3. The North/South difference in sunlight – mean effective UV radiation (UVR) at 3 UK sites.
Glasgow has substantially less sun than Camborne (SW England) in all months except June. UVR measured
at 12 hrs GMT and weighted for biological effectiveness in the skin. Source: National Radiological
Protection Board (unpublished data). From Nutrition and Bone Health, Dept of Health Report on Health
and Social Subjects, No 49, Stationery Office, 1998 [3]
Driscoll’s comparison shows that Glasgow obtains the same amount of UVB in the effective range as Kiruna, which
is above the Arctic Circle in northern Sweden. Lund in southern Sweden is on almost the same latitude as Glasgow
and obtains 50% more sun, showing the effect of cloud and overcast skies on our western coast. Durham, which is
on the east coast of England and only 70 miles south of Glasgow, also obtains 50% more sun than Glasgow. This shows
that there are important East/West differences in sun over the British Isles as well as the north/south differences.
However the length of the summer season and the air temperature is as important as the total amount of
sunlight available in determining how much sun exposure people will get per year in a given locality. The summer
Figure 4. Scotland gets less sun than England because it is so much further north and because it is more
exposed to humid westerly and north westerly airstreams which bring cloudy weather and rain. England,
on the other hand, is relatively sheltered from the west by Ireland and by the Cumbrian mountains. The
sunniest places are on south facing coasts and flat coastal plains. Some sites along the south coast of
England from the Isle of Wight eastwards and the Channel Islands record more than 40% of the maximum
amount of sunshine possible in a year (1,800 hours out of 4,000). The Shetland Islands only achieve about
24% of the maximum possible sunshine. Map redrawn from Meteorological Office data.

Nowadays most healthy people in the UK get only about 5% of the vitamin D they need from their diet – fish,
meat, margarine and eggs being the main sources. Those who regularly eat oily fish may get a little more, but at most
they can get only 10% of the vitamin D they need for optimum health this way. In any case current official advice
from the UK Food Standards Agency is to eat fish no more than three times per week because sea water is pollut-
ed with toxins such as lead that are taken up by fish.
Fishisalsothebestsourceofomega-3fattyacidswhichhaveanumberofhealthbenefits.Sofishmealsthreetimes
a week are highly recommended. A fish oil supplement such as cod liver oil or halibut liver oil can also be highly
recommended as a source of both omega-3 fatty acids and vitamin D. However the recommended dose of these fish
oils does not provide enough vitamin D to enable optimum levels to be reached. Purified omega-3 fish oils, which are
widely promoted, generally contain no vitamin D. So fish oils of all kinds need to be supplemented with vitamin D in
another form. Although food generally provides little vitamin D it is nevertheless an important source of vitamin D for
people who get little exposure to the sun and may prevent the most extreme ill health caused by insufficient D, such
as rickets or osteomalacia. Vegetarians, especially vegans, are at particularly high risk of the more severe types of D
insufficiency and it is specially important for them to actively seek exposure to the sun and/or take a vitamin D
supplement. An optimal level of vitamin D can only be obtained in Scotland by taking a supplement.
3. Remarkable list of D diseases
Diseases associated with insufficient vitamin D, and now believed to be caused at least in part by D-insufficiency,
include: multiple sclerosis, diabetes (1 and 2), hypertension, arthritis, tuberculosis, several different types of cancer,
cardiovascular disease, pre-eclampsia (a serious complication of pregnancy), dental decay and gum disease,
Crohn’s disease and other autoimmune diseases, as well as the classic bone diseases, rickets, osteoporosis and
osteomalacia [20, 29-31].
Until recently it was hard to believe that vitamin D could have an important role in so many different diseases.
Researchers found it difficult to understand how one factor, insufficient vitamin D, could even be a partial cause
of so many different diseases. However we now know that vitamin D is processed locally in more than 30 different
tissues and organs of the human body. It has been shown to act on tissues causing activation of 1000 different genes,
differentiation of cells, and regulated cell death (apoptosis) [32].
Insufficient vitamin D might cause disease in a particular organ and not another as a result of timing, genetic
background and other circumstances. Detailed biological evidence explains the mechanism of action of vitamin D
in heart disease [33, 34], cancer [35, 36] and a number of other diseases not just those of bone.
4. The ‘Scottish effect’ – an explanation
Deaths from all causes among people of working age are more frequent in Scotland than any other Western Euro-
pean country – see Figure 5. Furthermore Scotland has a higher overall mortality than England and Wales that
cannot be explained by differences in smoking, alcohol consumption, poverty or other established risk factors. This
hitherto unexplained excess mortality in Scotland compared with England and other industrial countries has been
called the “Scottish effect” [1, 2, 13].
The health deficit in Scotland effects people in all walks of life. In the 1980s, for example, Scots from all social
classes died earlier than people in the same social class as them in the rest of the UK. The Scottish Council
Foundation’s report on The Possible Scot [2] puts it this way: “The relative position of Scotland as a whole has
worsened at a time when average measures of income, unemployment and housing standards have improved.
Scotland's health is worse across the board than in equivalent areas of the United Kingdom. That suggests there may
be factors other than relative deprivation that underlie Scotland's poor figures. There may be an additional Scot-
tish Effect. The existence and nature of this effect urgently requires further exploration…”
Different levels of vitamin D in the Scottish and English populations, caused ultimately by differences between
the Scottish and English climate, could explain the Scottish effect [5]. This explanation does not appear to have been
considered before because low vitamin D levels have only recently been recognised as an important risk factor for
cancer, heart disease, hypertension and other common ills. Several recent reports on health in Scotland make
little or no mention of vitamin D showing that the seriousness of vitamin D deprivation in Scotland and its
consequences are poorly understood by UK health professionals including high profile nutritionists and food
experts [2, 12, 14-17].
Being born in Scotland and spending early years in the country appears to be enough to increase the risk of
season starts some three weeks earlier and finishes some three weeks later in Scotland compared with southern
England while lower air temperatures throughout the summer mean that arms and shoulders are generally much less
often exposed. The result is that most people in Scotland get much less exposure to active UVB than in more
southern latitudes and so make less vitamin D.
So it is hardly surprising that Scots are twice as likely as southern English to have a low vitamin D level (below
either 25 or 40 nmol/L) [5]. The optimum level of vitamin D is now generally accepted to be above 75 nmol/L and
in summer 75 per cent of Scots fail to reach this level compared with 57 per cent of people in southern England. While
in winter, 92 per cent of Scots fail to reach the optimal level compared to 86 per cent of people in southern
England [24]. These figures show that vitamin D insufficiency is a very serious problem in all parts of Britain but
Scotland is at the extreme end and so the overall effects of vitamin D insufficiency are very grave indeed for
Scotland.
And the problem is likely to get worse and not better unless active steps are taken. People today spend less time
outdoors than they used to do and so obtain less vitamin D from the sun than in the past. Television, computers,
cars, central heating and air conditioning all encourage indoor living. Wearing of long trousers instead of shorts or
skirts by children reduces sun exposure very significantly. Furthermore many cosmetics now contain sunblock that
reduces the amount of vitamin D to be obtained by casual exposure to the sun.
Heavy promotion by government of advice to avoid exposure to the sun in the middle of the day, aimed at
reducing the risk of skin cancer, has further reduced vitamin D levels. All these factors have combined so that the
problem of insufficient vitamin D is more acute now than it has ever been since the first half of the 20th century
when heavy air pollution from coal fires and factories prevented UVB rays reaching people in cities and towns.
Rickets was then common in European cities, particularly Glasgow and other Scots industrial areas. The steady
increase in incidence in the UK of diseases such as multiple sclerosis and diabetes type 1, where vitamin D appears
to play a crucial role, may be explained at least in part by these changes in everyday exposure to the sun.
2. Eskimos, Lapps – and Scots
In winter the sun is not strong enough in Scotland, or indeed in any country north of 37° latitude, to make a useful
amount of vitamin D. Vitamin D has a half life in vivo of two to three months [25] and so winter levels of vitamin D
are unlikely to remain optimal for people in Scotland except perhaps for a few individuals who build up large stores
of the vitamin by regular sunbathing in summer, or go for a winter sunshine holiday.
Eskimos (Inuit), who live above the Arctic Circle where summers are very short, get most of their vitamin D from
their marine diet. Not only fish, but also whale, seal and other marine meats and blubber are a good source of vitamin
D.Eskimos,wholiveinlandinAlaskaandnorthernCanadaandsurvivebyhuntingcaribou,tradewithothersonthecoast
toobtainconcentratedfishoilwhichisadelicacyforthemandmakesanimportantcontributiontotheirdiet[26].Lapps,
who also live close to the Arctic Circle, obtain much vitamin D from reindeer meat and stomach contents that is rich
in the vitamin because the reindeer themselves eat “moss” (actually a lichen) rich in vitamin D.
In Scotland the “vitamin D winter”, the darker months when there is insufficient active UVB for synthesis of the
vitamin, lasts four to six weeks longer than in southern England. So stores of vitamin D in the body are more likely to
run down to dangerously low levels during the winter in Scotland than in England, as has been well documented [5].
Changes in diet in Scotland over the last 100 years have probably made the winter shortage of vitamin D today
more extreme than before, at least in coastal areas of the country. In 1868 Hutchison recorded the diets of agricultural
labourers in Scotland and at that time fish appear to have played a larger part than meat in the diet of the families
of a ploughman and a shepherd, two of the examples given [27]. We cannot generalise from two observations but
for many Scots, especially those living in coastal areas, fish used to be a more important part of the diet than it is
now. Salted and smoked herring (kippers), which are rich in vitamin D, were a more common part of the Scots diet
in the past. Now herring stocks are seriously depleted and some local races of herring have been completely wiped
out while white fish stocks have also been seriously reduced [28].
This has happened since the use of steam trawlers began in the second half of the 19th century. Use of steam
engines allowed boats to go further, survive more hostile weather and tow bigger nets. New markets for Scots’ fish
opened up in England following development of the railways and fish stocks were devastated [28]. Now fish is no
longer the cheap food that once nourished the poor and provided an important quantity of vitamin D. (See
Chapter 6 for more about changes in fish stocks and its possible effects on diseases in the north Atlantic islands).
In Scandinavia fish has remained a more important part of the diet and many more people regularly take a supplement
of cod liver oil (which is rich in vitamin D) as a “health tonic”.

8 Health Research Forum Occasional Reports: No 3 Health Research Forum Occasional Reports: No 3 9
the overall conclusion that reasons for poor health in the West of Scotland are unclear.
However, there is one factor that the Aftershock report does not consider. The West of Scotland is the most
northerly of the 20 industrial areas compared in the report. Industrialisation involves moving from rural occupations
in the country into cities where work is indoors and workers often live in apartments where they get less exposure
to the sun. This factor must have a greater effect in areas that are further north, have a cloudy maritime climate and
have a colder air temperature in summer like the west of Scotland.
It might be thought instructive to make a direct comparison of Clydeside with Tyne, Wear and Tees, as can be
done with data in the Aftershock report. The comparison seems to be appropriate because both are regions where
shipbuilding and coal have been dominating industries, and they are so near in distance and latitude it might be thought
that there is little difference in sunlight. However there is a large difference in UVB (effective for vitamin D synthesis)
received on the west and east of the country, according to measurements made by the National Radiological
Protection Board. People in Durham get some 50% more effective UVB than people in Glasgow [23]. This must be
because Durham is sheltered by mountains to the north and west which precipitate much of the moisture coming
from westerly and north-westerly Atlantic winds, while Glasgow is fully exposed to the wet westerlies.
Other factors such as availability of outdoor play areas for children, sports fields for adults, balconies on blocks
of flats, advice about sun exposure, availability of vitamin D supplements for children and adults may all differ
critically between the industrial areas being considered in various parts of Europe, and could account for differences
in health between them. This suggestion is easily tested by measuring vitamin D levels in people living in these
areas. However it will be necessary to study large numbers to obtain a significant result because it is those people
at the far end of the statistical distribution who are most deficient in vitamin D and are most likely to show disease.
Looking for the cause of the difference in mortality between Scotland and England we find that Scotland gen-
erally has a higher incidence of chronic diseases that are caused at least in part by insufficient vitamin D. Indeed in-
sufficient vitamin D and the northern location that causes it may explain most of the otherwise unaccounted dif-
ferences in health between the two UK regions, and also may account for some of the difference between Scottish
industrial areas and those on the continent. In the sections that follow I examine how the incidence or prevalence
of several major diseases varies between Scotland and England together with evidence that suggests the differences
may be caused at least in part by vitamin D insufficiency.
premature death. People born in Scotland but moving to England have a greater risk of death (higher standardised
mortality rate or SMR) than people born and living in England [37]. While people born in England but moving to Scot-
land have a lower risk of death (lower SMR) than native Scots, born and bred [38]. This suggests that there is some
factor in the early life of many Scots that leads to a premature death. Insufficient vitamin D during pregnancy, growth
and development could be the missing factor and evidence reviewed below supports such an explanation.
5. An early death in Scotland: Mortality studies
During the decade 1988-98 life expectancy in Scotland was consistently lower than other EC countries – the only
exception was Portuguese men whose life expectancy is marginally lower than Scottish men [1]. Scotland had
higher premature mortality rates than all other countries in Europe between 1991 and 1997 and a higher premature
mortality rate than every region in the UK including regions in the north of England [39]. Even so health has
actually been improving in Scotland, but not as rapidly as in other European countries, and at the present rate
Scotland will never catch up.
Premature mortality in the Strathclyde (Glasgow) region, where deprivation is greatest, is particularly high.
However high deprivation in this area cannot by itself account for the difference between Scotland and England
because all Scottish regions except Grampian had above average premature mortality for the UK (1991-97). Indeed
the difference in life expectancy between Scotland and England is increasing. In 1981 life expectancy was 12%
lower in Scotland than in England increasing to 15% lower in 2001 [1].
In the past the higher premature mortality in Scotland has been explained by a higher level of deprivation in
Scotland [40]. However, after adjustments are made for differences in deprivation, age and sex structure of the
population premature mortality in Scotland was still 8.2% greater than England in 2001 [1]. And when the most
deprived areas of Scotland were compared with equally deprived areas of England and Wales premature
mortality was found to be 17% higher in Scotland.
Industrial decline has often been given as the reason for Scotland’s poor health record. A new report,
The Aftershock of De-industrialisation, compares the West of Scotland with 20 other old industrial regions in the
UK and Europe such as the Ruhr, Alsace-Lorraine and Silesia in Poland as well as Northern Ireland, Tyne and Wear
and the Tees Valley [41]. The report finds that mortality in Scotland is comparatively high and the rate of improve-
ment in mortality is relatively slow compared with these other industrial areas, even though Scotland compares
favourably when it comes to wealth, unemployment and educational attainment.
The authors consider a number of possible explanations: in particular higher levels of alcohol consumption,
smoking among women, obesity, deprivation and possibly greater levels of inequality. The report comes to
Figure 5. Life
expectancy at birth
(1995-1997) by country
and British
Government region.
Notice regions are in a
rough north/south
gradient, but care must
be taken not to over-
interpret this because
the figures have not
been corrected for
smoking, alcohol or
poverty. Nevertheless
Scotland has the
lowest life expectancy
of all UK countries or
regions. Source ONS
Figure 6. Excess
mortality in
Scotland
compared with
England by
comparison of
mortality rates
standardised for
deprivation. From
Hanlon et al.,
Journal of Public
Health. 27 (2) pp
199-204.

10 Health Research Forum Occasional Reports: No 3 Health Research Forum Occasional Reports: No 3 11
men living in the south of England [49], while the place where the men spent most of their adult lives had a much
stronger influence on their blood pressure than the place where they were born and brought up.
South Asians living in Scotland but born elsewhere might be reassured because they do not show an excess
mortality from heart disease compared with native Scots. However this is only because the inhospitable nature of
the Scots environment affects them equally as it does native Scots. South Asians living in Scotland have a substantial
excess of heart disease compared with South Asians living in England, so mirroring the excess heart disease in Scots
compared with the English [38].
Similar regional variation has been found for other cardiovascular and respiratory risk factors in the UK [57]. These
results are what would be expected if sun exposure were a major factor in heart disease and hypertension in
Scotland. Indeed almost half of the variance in mortality from heart disease in different districts of the UK can be
explained by variation in hours of sunshine suggesting directly that greater exposure to the sun might save lives [58].
Observations from the NHANES study (National Health and Nutrition Examination Survey) provide support for
a general effect of vitamin D in maintaining blood vessels in a good operational state [59]. NHANES investigators
found that low serum vitamin D levels are associated with a higher prevalence of peripheral arterial disease. By way
of explanation of this effect they remarked: “Vitamin D is an inhibitor of the renin-angiotensin system and has anti-
inflammatory and anticoagulant properties.”
The interpretation offered here that vitamin D insufficiency plays a substantial role in regional variation in the
incidence of heart disease and accounts for the north/south gradient in the UK might be tested by re-examination
of stored blood and data held by the British Regional Heart Study. I first suggested this to leaders of BRHS in 2004
but funds were not then available to test it, perhaps because the importance of vitamin D was not so widely
appreciated at that time. It seems likely that regional variation in vitamin D levels may be an important missing
factor in their account of heart disease in Britain.
2. Blood pressure and stroke – the quiet killers
The lower average levels of vitamin D in Scotland compared with England can account at least in part for the very
high incidence of stroke north of the border. Low levels of vitamin D are now recognised to be an important risk
factor for raised blood pressure, which is a major cause of stroke. Raised blood pressure (hypertension) is also
recognised as a major risk factor for heart disease earning it the title of the quiet killer.
The risk factors generally recognised for raised blood pressure are the same as for heart disease and stroke:
smoking, diabetes, diet (insufficient fruit and vegetables), lack of exercise, obesity and age. To these we must now
add low levels of vitamin D. The effect of insufficient vitamin D on blood pressure may explain the north/south
gradient for both stroke and heart disease in the UK [51].
The involvement of sunlight and vitamin D in determining blood pressure was elaborated by Stephen Rostand
in 1997 [52]. He showed that differences in sun exposure and vitamin D levels could explain seasonal changes in blood
pressure, variation of blood pressure with latitude, and differences in blood pressure between races. His astute
analysis has recently been supported by two major epidemiological studies. Some 1,800 individuals were followed
for four years in the Health Professionals Follow-up study and the Nurses Health Study [53]. Men with low levels
of vitamin D (less than 15 ng/ml or 37.5 nmol/L) were six times more likely to have raised blood pressure than those
with high levels of vitamin D (greater than 30 ng/ml or 75 nmol/L). While women with low D were 2.67 times more
likely than women with high D to have raised blood pressure.
This finding was confirmed by another two studies. The third National Health and Nutrition Examination
Survey found that people with a vitamin D level greater than 32 ng/ml or 80 nmol/L had a blood pressure 20% less
than people who had vitamin D levels less than 20 ng/ml or 50 nmol/L [54]. Differences between this study and
the Health Professionals and Nurses study may be accounted for by the way the blood samples were taken, since
there is a large seasonal variation in blood levels of vitamin D that can influence findings when it is not fully
controlled. Another study of people over 65 in Amsterdam found that those with raised parathyroid hormone (which
is generally elevated when vitamin D levels are reduced) also tended to have raised blood pressure [60].
Additional evidence showing that blood pressure is strongly influenced by vitamin D levels comes from
clinical trials showing that blood pressure may be lowered by exposing the body repeatedly to UV or by taking a
vitamin D supplement. Whole body radiation with UVB on a sunbed three times a week for several weeks has been
reported to reduce both systolic and diastolic blood pressure by an average 6 mms of mercury [61] Controls exposed
to UVA radiation, which does not induce production of vitamin D, showed no reduction in blood pressure.
A vitamin D supplement of 800 IUs per day plus calcium for eight weeks, lowered systolic blood pressure by 5
mm of mercury in 81% of people taking it, whereas calcium alone reduced blood pressure in only 47% of people
Chapter 2:
Scotland’s major killers
1. Heart and blood vessel disease
People who live in Scotland have a greater risk of heart and blood vessel disease and consequent death compared
with people almost anywhere else in Europe. Only the Finns suffer from more cardiovascular disease than the Scots.
Insufficient vitamin D is now known to be a risk factor for heart disease, hypertension and stroke and these diseases
account for a substantial part of the “Scottish effect” – the difference in mortality between Scotland and England.
Finnish men currently have the European record for heart disease previously held by Scottish men, while
Scottish women have retained the highest mortality rate for heart disease in Europe since the 1950s [42]. And apart
from Portugal, Scotland has the highest mortality rate from stroke in Western Europe [42].
The high incidence of stroke in Portugal may be due, at least in part, to their high consumption of salt, especially
salt fish. Salt is well known as a risk factor for raised blood pressure and stroke. In view of the multi-factorial cause
of most chronic diseases, and particularly cardiovascular and cerebrovascular disease (stroke), it is perhaps surprising
that correlations with vitamin D levels, north/south location, latitude, and hours of sunlight, all stand out as
clearly as they do.
The high rate of heart disease in Scotland cannot be explained by conventional risk factors [43]. Richard
Mitchell and colleagues warn [43]: “Greater prevalence of individual IHD [ischaemic heart disease] risk factors among
the Scots explains relatively little of their higher rates of heart disease, relative to the English. This means that
current policy interventions aimed at behavioural change are unlikely to narrow the IHD gap between these
neighbouring nations.” It seems likely that the poor heart health of Scots is caused by some other risk factor that
has not been considered up to now.
In 1995 an Australian, Robert Scragg, brought together significant observations suggesting that vitamin D may be
an important risk factor for heart disease [44]. He argued cogently that studies of latitude, altitude, and season
consistently suggest that sunlight is a significant risk factor in heart disease [45-48]. Scragg noted differences in heart
disease and hypertension between Scotland and England which could not be accounted for by recognised risk
factors [49].
North/south gradient in heart disease
The “north/south gradient” in heart disease and stroke continued to be a puzzle and could not be accounted for
entirely by known variables leaving climate as a possible explanation of the remaining residual variance [50, 51].
Morris and colleagues have made many investigations of risk factors for heart disease. However the relationship with
climate was obscured for them because one of the variables they used for explanatory purposes was hypertension
(raised blood pressure) which itself has been shown to display a north/south gradient [52, 53].
Raised blood pressure has been known for some time to be associated with lower levels of sun exposure and/or
insufficient vitamin D in the diet, and this relationship has been confirmed by a recent study showing that plasma
levels of vitamin D* are inversely associated with the risk of high blood pressure [53]. Furthermore blood pressure
(systolic) in normal healthy people has also been found to vary with their vitamin D level – people with higher blood
pressure have lower vitamin D [54].
So the overall north/south difference in heart disease plus hypertension that may be attributed to an unknown
geographical factor, probably sunlight, must be substantially larger than the residual originally considered by
Morris. This suggests an important role for sunlight in cardiovascular disease that has not hitherto been widely
recognised. Confirmation that a biochemical difference lies behind the north/south gradient of heart disease in Eu-
rope comes from a recent study of low-density lipoprotein (LDL) that, with the exception of Italy, shows a similar
gradient across the continent. LDL is an established risk factor for atherosclerosis and hence for coronary artery and
cerebrovascular disease [55].
Men born in the northern part of the UK who move to the south have lower risks of cardiovascular disease and
death compared with those who remain at home in the north. Those migrating south acquire similar risks to those
born and living in the south, while men born in the south who move north increase their risk of cardiovascular
disease and death [56]. Similarly men living in Scotland have been found to have a higher mean blood pressure than
* all measurements of vitamin D referred to in the book are made as 25(OH)D which is now well established as the standard.

12 Health Research Forum Occasional Reports: No 3
heart failure [82]. Greater benefits may occur if vitamin D is used in an early stage of heart disease or for prevention.
4. Heart failure in infants: tip of an iceberg
Children with no obvious structural defect of the heart may suffer from heart failure caused by vitamin D deficiency,
which would be fatal without modern treatments. This type of heart muscle failure appears to be more common
in Scotland than in other parts of the British Isles. The case frequency in Scotland is 1.27 per 100,000 compared with
0.71 in southern England [85]. However the numbers in this survey are relatively small (12 cases in Scotland and 36
in southern England) so the difference between the two countries could be a matter of chance.
Heart failure, heart muscle disease, and myocarditis in children could all be caused by vitamin D deficiency says
Dr David Sane in correspondence in the journal Circulation [86]. He points to evidence consistent with the idea that
insufficient exposure to the sun may be a risk factor for heart failure in children. A higher incidence of unexplained
heart failure (that is heart failure induced by heart muscle disease without any anatomical defect) is found in
children in New England compared with the central south western United States [87]. Also black children in the US,
who are more prone to vitamin D deficiency, have higher rates of cardiomyopathy than whites [87].
Dr Sane suggests that paediatric patients with heart failure should be screened for vitamin D deficiency. Replying
to Dr Sane’s letter in Circulation, Dr Michael Burch and colleagues suggest that “as many as 25% of cases of infant
heart failure in South East England may be caused by vitamin D deficiency and conceivably it may be the most
common cause of infant heart failure in breast fed, dark skinned infants” [88]. In the UK one third of these children
have been found to die or require heart transplantation within a year of presentation [85]. Heart failure may also ac-
count for a proportion of unexplained sudden deaths of infants, that is cot deaths, also known as sudden infant death
syndrome (SIDS).
A study of 16 cases of infant heart failure from hospitals in south east England has brought wider recognition
for the disease which, apart from a few isolated cases, seems to have been overlooked until now [89]. The 16
cases studied by Dr Burch and colleagues at Great Ormond Street Hospital for Children and other London
Hospitals all came from families of Asian or African ethnic origin and all the infants were breast-fed. Most presented
at the end of winter (February to May) when vitamin D levels are lowest. Breast milk contains very little vitamin D,
except when the mother is very well supplemented with the vitamin, whereas formula milk is fortified with
vitamin D.
Dr Michael Burch, the paediatric cardiologist who drew the 16 cases of infant heart failure together, said: “Life
threatening heart failure occurring in babies in 21st century London, just from failure to be given a vitamin, is a
shocking fact.”
The infants had all been admitted as emergencies to intensive care units – 10 were suffering from heart failure and
six had suffered a cardiac arrest. All the infants were profoundly deficient in calcium and vitamin D and had high
levels of parathyroid hormone. Ten of the infants had radiological evidence of rickets. Three died and two were
scheduled for heart transplants. However all the survivors, including those scheduled for transplant, responded to vi-
tamin D and calcium plus anti-heart-failure medication, and made slow but good recoveries without transplantation.
Finding 16 cases over six years in the south east of England alone suggests that there are likely to be many more
in the UK. The London doctors point out that the underlying problem is probably even more extensive: “It deserves
emphasis that the infants in this series had overt and severe clinical heart failure, and it seems very likely that many
infants from these ethnic groups would have had undetected sub-clinical, but potentially important, cardiac
abnormality during the same era... It is concerning that none of the mothers or infants were receiving the
recommended vitamin D supplementation”.
So vitamin D deficiency is an important, and possibly even common, cause of illness in infants in the UK. One
in five Asian schoolchildren examined in Glasgow were found to suffer from low calcium in their blood or X-ray
evidence of rickets compared with only one in ten in England [90]. Vitamin D deficiency has not until now been well
recognised as a cause of infant heart failure. Large studies have been made of cardiomyopathy (heart muscle dis-
ease) in infants from North America and Australia but vitamin D deficiency does not seem to have been considered
as a possible cause of infant heart failure in these cases [91, 92].
Mothers and infants in Scotland, as in England, have not generally been given a vitamin D supplement in recent
years. The lack of supplements for mothers and infants is a result of failings in government policy which can only
be described as negligent [93]. More details are given below, see: Westminster bungles supply of infant vitamin, and,
Rickets and fractures: Asians in Glasgow.
treated [62]. Other trials of alphacalcidol, a synthetic form of calcitriol, the active hormone form of vitamin D, have
shown that this too may reduce blood pressure of men aged 61 to 65 by an average of 9 mmm mercury [63].
Increased blood pressure is closely associated with an increase in risk of stroke [64]. Furthermore lowering blood
pressure is well known to reduce the risk of a first or subsequent stroke [65, 66]. Since vitamin D lowers blood pressure
it may be expected that vitamin D might also be effective in preventing stroke. Indeed people over 65 in Finland with
a low intake of vitamin D or a low serum level of the vitamin have been found to be at increased risk of stroke when
observed over a 10 year period [67]; and a study in Cambridge found that 44 patients who had an acute stroke had
reduced levels of vitamin D compared with controls [68]. A population based study in Japan has found that the high-
est incidence of stroke occurs in the spring when vitamin D levels are at their lowest regardless of age, sex and other
risk factors and similar seasonal occurrence of stroke has been found in many other countries [69].
So it seems very likely that the high incidence of stroke in Scotland could be reduced if levels of vitamin D in
the population could be raised. Vitamin D may also be effective in lowering blood pressure and improving function
of blood vessels in stroke patients. Dr Miles Witham and others are currently testing this in a trial at Dundee
University.
3. Heart failure – vitamin D can help
Heart failure is a major cause of illness and death in Scotland, as it is in most industrial countries. In 2003 there were
estimated to be 40,000 men and 45,000 women aged 45 or over with heart failure in Scotland. This number is
forecast to be increasing rapidly with an extra 20,000 people in Scotland developing heart failure by 2020, if age
changes in the Scottish population occur as expected. Hospital admissions for heart failure in Scotland are forecast
to increase by 52% for men and 16 for women by 2020 [70].
Heart failure appears to be more common in Glasgow than in the English West Midlands suggesting that it might
account in part for the “Scottish effect” on mortality. Dr Theresa McDonagh of the Western Infirmary, Glasgow, found
that 2.9% of a sample of 1,640 people aged 25 to 74 from north Glasgow had definite heart failure, measured as left
ventricular systolic dysfunction [71]. This compares with 1.8% of 3960 people aged 45 plus years from the West
Midlands with definite heart failure studied by doctors at Birmingham University [72].*
The importance of vitamin D as a risk factor in heart disease is not yet widely appreciated although it is now well
established in clinical studies [73]. Zittermann, for example, has reviewed the evidence [74] and Michos and Blumenthal
have commented in some detail in an editorial in the journal Circulation [75].
Vitamin D appears to be effective as an anti-inflammatory in heart failure. Zittermann [33, 76-80], Weber [81],
Vieth [82], and Schleitoff [80] provide detailed explanations of how they believe vitamin D insufficiency acts as a
risk factor for cardiovascular events and for heart failure. Mechanisms by which vitamin D may act to prevent heart
disease include: inhibition of vascular smooth muscle proliferation, inhibition of vascular calcification, down
regulation of pro-inflammatory cytokines, the up regulation of anti-inflammatory cytokines, and action as a
negative regulator of the renin-angiotensin system. And recently vitamin D has been shown to directly modulate
vascular tone by reducing calcium influx into endothelial cells, so reducing production of endothelium-derived
contraction factors [83].
Vitamin D may also protect against atherosclerosis, the basic process that causes blocking of arteries. Low
levels of vitamin D in blood are associated with a higher prevalence of peripheral artery disease in the US
National Health and Nutrition Examination Survey (NHANES) [59]. Furthermore a randomised trial undertaken in
Dundee has found that a single large dose of 100,000 IUs vitamin D2 improves endothelial function in patients with
diabetes type 2 [84].
An impaired vitamin D and parathyroid hormone axis seems to be a part of the heart failure syndrome [81] and
treatment with vitamin D as an anti-inflammatory appears to be effective in patients with heart failure [80]. Patients
may enter a vicious circle of low vitamin D levels and high inflammatory cytokines if vitamin D deficiency persists.
However, as Vieth points out, it is ambitious to hope for a dramatic beneficial effect of vitamin D at a late stage in
* The Scottish doctors used a stricter criterion for the left ventricular ejection fraction of <30% compared with <40% used by the Eng-
lish doctors. Furthermore the Scottish sample included people under 45 years of age. It seems that a true like-for-like comparison of
the results of the two surveys would produce an even greater difference between Glasgow and the West Midlands. However people
in north Glasgow cannot be taken as representative of Scotland as a whole, nor West Midlanders of England as a whole. Also there
could have been other technical differences between the methods used by the two groups. So these findings, while giving a possible
indication, cannot be safely generalised to Scotland or England as a whole.

Vitamin D programmes genes and cell death
Scottish rates for bowel (colorectal) cancer were the highest in Europe until the 1970s and remain high, although
Ireland, Denmark and Austria now have similar high mortality rates for bowel cancer. The incidence of bowel
cancer in Europe varies about four fold when the highest and lowest incidence rates are compared and internationally
rates vary 60-fold [101]. A UK survey of people aged 50-69 years found that bowel cancer is almost twice as
common in the Scottish areas surveyed (Grampian, Tayside and Fife) compared with the English areas (Coventry and
Warwickshire) [102]. Many studies using different methodologies have now established a link between sun
exposure, vitamin D in the diet or serum, and bowel cancer [94, 100, 103].
The suggestion that one substance, vitamin D, could have such a profound effect on cancers of several types was
at first greeted with disbelief by some scientists. But we should no longer be surprised. Receptors for vitamin D have
been found in almost every tissue in the body. Vitamin D is processed locally into its active hormone form in each
organ or tissue in a way that is individually specified by the genes.
In its active hormone form 1,25(OH)2D, vitamin D controls more than 1000 genes including genes responsible for
the regulation of cellular proliferation, programmed cell death (apoptosis), and growth of blood vessels [32] . This
proliferation of blood vessels known as angiogenesis occurs when tumours sequester their own blood supply
enabling them to grow even faster. Vitamin D also decreases cellular proliferation of both normal and cancer cells
and induces them to differentiate into their final form – rather than remain as intermediate forms which are at risk
of developing into cancer cells [35, 104].
There is now a consensus of international experts who agree that the risk of cancer is likely to be reduced by
increasing the average individual’s exposure to the sun and/or by taking a vitamin D supplement of about 1000 IUs
per day or more [9-11, 20, 30, 94, 105-107]. This conclusion is backed up by the results of a double blind randomised
trial in women who had an average age of 67 years [11]. The women were given 1100 IUs of vitamin D/day with the
original intention of studying benefit in preventing fractures but it was found after four years that there was a 77%
reduction in cancer among the women taking vitamin D compared with those taking a placebo.
William Grant, a former NASA scientist now dedicated to work on vitamin D and sunlight, has estimated that
17 different types of cancer are sensitive to UV, that is to say insufficient vitamin D puts a person at increased risk
of contracting the cancer and/or dying from it [108]. This number is obtained by comparing figures for mortality
from cancer with intensity of UV radiation in different countries, states or regions. The method is controversial but
has produced results that are broadly consistent with other methods and so compels our attention. Indeed it may
be that insufficient vitamin D is a risk factor for most, if not all, types of cancer because some cancers are too rare
to be assessed by Grant’s method of analysis. However a more conservative assessment concludes that only in the
case of bowel and colon cancer, breast cancer and lymphoma (lymph gland cancer) is there clear evidence that
insufficient vitamin D is a risk factor [107, 109].
There have been relatively few negative findings on the relationship between cancer and vitamin D. However four
studies now show that the risk of prostate cancer is not reduced in people with higher blood levels of vitamin D
[110]. Risk of multiple myeloma may be increased by sun exposure according to one study which also found that risk
of the more common lymphoma is reduced by sun exposure [107]. This is the first such finding for multiple
myeloma and so should be confirmed before it is accepted while the reduction of risk of lymphoma associated with
increased sun exposure has been found in three other studies.
Cancer deaths could be reduced by 14 to 19% in the UK if everyone took a supplement of 1000 IUs of vitamin D
per day, according to Dr Grant’s calculations [108]. Simply going to live in a sunnier country such as the southern
United States may reduce the risk of dying from cancer by 50% or more, according to Dr Grant. For residents of
Scotland who do not wish to emigrate to sunnier climes a substantial reduction in risk of death from cancer may
be obtained if every opportunity is taken to sunbathe without burning or a vitamin D supplement is taken.
Summary: Scotland has a high incidence of cancer, which may account in part for the “Scottish effect”. Northern
latitude, low sun exposure and low vitamin D levels are associated with a high risk of cancer. Vitamin D has been shown
to reduce cancer risk in at least one trial. Boosting vitamin D levels in Scotland can be expected to reduce the
incidence of cancer substantially, reducing mortality in a step-change.
Summary: Vitamin D insufficiency plays an important part in raised blood pressure, and in heart failure of both
infants and old people. A higher incidence of vitamin D insufficiency in Scotland compared with England could
explain the higher incidence of heart disease and stroke in Scotland and account in part for the “ Scottish effect”.
An increase in vitamin D from sunlight and from supplements or food in Scotland might reasonably be expected
to lower mortality from heart disease and stroke.
5. Cancer: increased risk
International studies suggest that people living at high latitudes, such as northern Europe, are at increased risk
of death from many cancers including the most common types: breast, colon, pancreatic, prostate, and
ovarian cancers, and Hodgkin’s lymphoma [30, 94]. Scotland follows this pattern and has a relatively high incidence
of cancer compared with most other European countries – see Figure 7 [42]. Countries at high latitudes,
such as Scotland, have a relatively low intensity of sunlight and a relatively short summer season and so the
inhabitants obtain less exposure to UVB, and less vitamin D, which we now know makes them more vulnerable
to cancer.
Overall the cancer incidence in Scottish men is 16% above that of English men and cancer incidence in Scottish
women 13% above that of English women [95]. Much of this difference may be accounted for by differences in
smoking, alcohol consumption and possibly obesity [42] which vary geographically in complicated ways.
However mortality of Scottish smokers in Renfrew and Paisley from lung cancer is greater per cigarette smoked than
it is for English or American smokers [96]. This hint that there may be a geographical factor, such as ultra-violet
radiation, that acts as an additional risk factor for smoking is supported by a study showing that the geographical
relationship persists in a study of smoking in 111 countries [97].
Individual exposure to the sun and uptake of vitamin D can vary almost as much from personal habits as from
latitude even in a sub-tropical climate [98]. The interaction of several risk factors leads to considerable regional
variation in cancer incidence within Scotland and England tending to mask any north/south effect on incidence that
may generally be found elsewhere over larger ranges of latitude. Even so some cancers have been found to be
especially frequent in Scotland.
The mortality for breast cancer in Scotland is close to the European maximum [42]. Other observations support
the suggestion that the reason for this is low levels of vitamin D. Women who do not get regular exposure to
sunlight, and do not get much vitamin D from other sources, have a significantly higher incidence of breast cancer
[94, 99, 100]. Women in the lowest quartile for serum vitamin D have been found to have a risk of breast cancer five
times higher than those in the highest quartile for serum vitamin D.
Figure 7. Mortality rates
(age-standardised) for all
malignancies per 100,000
population for selected
European countries. The
large numbers of smokers
in Scotland ensures that
Scotland comes low in
this list but that is only
part of the story. Source
WHO

At least 80 known autoimmune diseases
One person in 30 suffers from an autoimmune disease of some kind and one new case occurs each year for every
1000 people in the United States [125, 126]. There are more than 80 known autoimmune diseases [127]. Complicated
interactions of environment, genes and stage of growth will determine which autoimmune disease a person might
develop. The environmental influences are likely to include vitamin D availability at various crucial times in
development and growth, diet, and timing of infectious disease.
The most common autoimmune diseases other than the big four and thyroid disease are: vitiligo (a skin
disorder causing white patches), glomerulonephritis (a kidney disease), systemic lupus erythematosis (inflammation
of connective tissue e.g. skin), biliary cirrhosis (a liver disease), myasthenia gravis (general muscle weakness), and
systemic sclerosis (also called scleroderma, affects skin and many other organs) [126]. But there are also a substan-
tial number of relatively rare autoimmune syndromes with exotic names such as Goodpasture’s, Addison’s, Cogan’s,
and Sjogren’s.
Much of the research on autoimmune diseases focuses on them individually but understanding may be gained
by comparing them and considering possible common features. In his classic discussion of how to identify causes
of disease from epidemiological observations Bradford Hill suggests that analogy provides a useful means of
recognising cause, especially when it is supported by a cogent biological model and experimental evidence [128].
So autoimmune diseases may be considered together as a family of analogous diseases and the question natural-
ly arises whether they may not have a common cause.
Present understanding of multiple sclerosis and diabetes type 1 suggests that insufficient vitamin D or sunlight
in early life or later is a cause of these two diseases. So, following the classic reasoning by analogy of Bradford Hill,
we can predict that insufficient vitamin D may also be a cause of other autoimmune diseases such as rheumatoid
arthritis and inflammatory bowel disease. Likewise the analogy may be extended to the whole family of 80 or more
autoimmune diseases. And this leads to the expectation and hope that the same practical measures for prevention
may be effective i.e. taking of vitamin D supplements, especially in early life but possibly later too, and greater
exposure to the sun.
Indeed this reasoning is already bearing fruit. People with Behçet’s syndrome, an allergic condition involving in-
flammation of the eye together with ulcers in the mouth and on the genitals, have been found to have low levels
of vitamin D (25(OH)D) in serum [129]. In one study the serum level of vitamin D in people with Behçet’s was found
to vary inversely with the amount of toll-like receptors. These receptors are involved in the process of inflamma-
tion and are produced in larger amounts by people with Behçet’s. When white cells from these people were
treated with vitamin D in the test tube the formation of the toll-like receptors was suppressed giving hope that vi-
tamin D might have therapeutic potential for Behçet’s disease.
Experimental evidence from mice is now accumulating to support use of vitamin D to prevent and/or treat sev-
eral autoimmune diseases. Diseases for which there is experimental evidence in animals supporting use of vitamin
D for prevention or therapy include systemic lupus erythematosus, allergic encephalomyelitis, collagen induced
arthritis, Lyme arthritis, and inflammatory bowel disease [130, 131]. And vitamin D is also beginning to be recognised
now as beneficial for treatment of several auto-immune disorders in patients [132].
If the disease model to be considered in relation to Bradford Hill’s analogy is the broader category, immune sys-
tem disease, rather than autoimmune disease, then not only is asthma included but also hay fever, eczema,
coeliac disease and other allergies. Vitamin D may well be found to benefit these diseases but, apart from asthma,
evidence one way or another is not reviewed in this book.
2. The Big Four
2.1. Multiple sclerosis – a world record for Scotland
Multiple sclerosis is more frequent in Scotland than any other country in the world where its occurrence has been
measured. Both the prevalence and incidence of the disease are higher in Scotland than anywhere else [133, 134]. On
Tayside (latitude 56.5° north) one person in 300 suffers from MS. As in other locations the disease is more common
among women than men: 236 women and 100 men per 100,000 on Tayside are affected by the disease as defined
by international criteria (age and sex standardised rates). In the Lothian and Border region [133], in the Grampian
region [135] and in Orkney and Shetland [136] prevalence rates are almost as high.
Northern Ireland has a prevalence of MS close to that of Scotland but prevalence in England and Wales is
typically half that of Scotland – see figure 8 [134]. Fewer studies have been made of incidence because they are more
Chapter 3:
Scotland’s bane: the epidemic of immune
system diseases
1. The silent epidemic
Three autoimmune diseases, multiple sclerosis, diabetes type 1, and Crohn’s disease occur more frequently in
Scotland than in England. A fourth autoimmune disease, rheumatoid arthritis, has a greater prevalence in the
United Kingdom than in other European countries. These four common diseases, the “Big Four”, occur as a result of
the body’s own immune system attacking other body tissues causing progressive and devastating illness.
Scientific evidence now suggests that vitamin D and/or sunlight, especially in early life, may protect against the big
four and that insufficient vitamin D is the common factor linking these diseases.
Taken together these four diseases can be seen to be part of a silent epidemic of autoimmune disease. Silent
because it is not widely understood that the big four diseases are linked and that the epidemic may involve dozens
of other autoimmune diseases, some rare. The epidemic of autoimmune disease appears to be a worldwide
phenomenon of our industrial age, but Scotland is particularly badly afflicted. Looking at multiple sclerosis alone
the figures show that Scotland is worse affected than anywhere else in the world [29, 111-113].
Furthermore autoimmune diseases appear to be increasing in incidence year on year but the seriousness of the
threat is not fully realised. The incidence of multiple sclerosis, diabetes type 1 and Crohn’s disease are all increas-
ing, while there is insufficient data on rheumatoid arthritis to know whether the incidence is changing or not.
Asthma, a related immune system disease, is also increasing steadily.
The reason for the increase seems to be our new ways of living, in particular modern life indoors, out of the sun.
These diseases are increasing in children who now get much less exposure to the sun than they used to. Children
get less exposure because fashion now dictates long trousers even for young children in both summer and winter.
As a result exposure of a child’s body to the sun may be reduced by a third or more. Greater use of cars, time spent
indoors watching TV and playing computer games all reduce the time spent outdoors. Use of suncreams and
advice aimed at preventing skin cancer further reduces exposure to the sun. Excess intake of calories and
insufficient exercise may also play a part in the increase in autoimmune disease.
Recognition of a common link in the increase in immune system disease, and of an epidemic that extends
beyond the big four, comes from studies of thyroid disease in Scotland. Hunter and colleagues found a twofold
increase in autoimmune disease of the thyroid in young people on Tayside during the 1990s. They remark that their
findings suggest “an increase in autoimmune thyroid disease, similar to the rising prevalence of type 1 diabetes,
possibly indicating a rising prevalence of autoimmunity in young people” [114, 115]. These immune system diseases
make a substantial contribution to the Scottish effect, the excess of chronic disease that plagues the country.
Vitamin D modulates the immune system
When self tolerance of body tissues breaks down as it does in autoimmune disease certain cells in the immune
system called T helper cells become activated, perhaps as the result of an environmental trigger such as infection
or perhaps because the immune system itself has failed to mature normally. The T helper cells then attack normal
body tissues causing chronic inflammation and increasing damage as the disease progresses [116-118]. The common
mechanism of these four diseases has been pointed out by a number of researchers and details have been well worked
out in animal studies [119-122].
T helper cells have receptors for vitamin D that enable the vitamin to interact with these cells and reduce
their activity. Vitamin D also “modulates” the immune system in other important ways. It suppresses secretion
of melatonin which plays a part in priming T helper cells [123], and promotes secretion of melanocyte stimulating
hormone which suppresses T helper cell activity [124]. These mechanisms have been well worked out in
genetically modified mice with “model diseases” – that is artificially created diseases that simulate multiple
sclerosis, diabetes type 1, rheumatoid arthritis or Crohn’s. In all four model diseases vitamin D deficiency has been
shown to accelerate disease while supplements of vitamin D suppress the diseases in these experimental
animals [122].

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