Why everyone with Parkinson's should take just one multivitamin a day
By Michael S. Okun
Now that I have entered my third decade of practicing as a Parkinson’s neurologist, I have observed an expansive number of ‘vitamin and supplement based strategies’ designed to treat Parkinson’s. April is Parkinson’s awareness month, and I thought it would be fun to share what I have learned about vitamins over many years of practice. I will attempt to make a strong argument that ‘everyone with Parkinson’s should be on one multi-vitamin a day,’ especially if taking levodopa replacement therapy. Everyone should be interfacing with their primary care physician (or practitioner) to have vitamin levels checked on a regular basis and vitamin replacement therapy adjusted as appropriate.
A nice article in June 2017 appeared in the Ottawa Citizen about the dangers of ‘overdoing’ vitamins.
There are many vitamins and supplements out there, so why not take them all?
I have met many persons with Parkinson’s who have adopted the strategy that ‘more is better.’ After many years of practice I have come to the realization that ‘less may be more,’ and that not all vitamins and all supplements are ‘risk-free.’
This was an article in futurity about polypharmacy.
What is carotenoderma?
There is a great picture and article you find on this condition at DermNet.
If you are taking vitamins and your skin takes on a ‘Halloween orange appearance,’ watch out as you may have ingested too much carotene.
The syndrome of carotenemia was described in 1919 by Hess and Meyers. Increasing your blood levels of beta-carotene does not however always result in carotenosis. It is when you start taking over 20 mg/day. A single carrot has for example ~4.0 mg.
Carotenoderma or orange discoloration of the skin is caused by ingestion of carotenoids. Eating too many fruits and vegetables high in carotene, or taking too many vitamins/supplements with carotene may result in the syndrome.
For those of you who are history buffs, during WWII, carotenemia was reported when folks switched to plant-based diets; as a result of food shortages.
Why are your feet numb?
Article in Daily Express 2017.
Vitamin B6 is commonly taken as part of regimens and B6 is in general a good thing. However, you know what they say, ‘sometimes you can have too much of a good thing.’
What is vitamin B6? Some experts refer to it as a ‘micronutrient,’ and your body requires some amount of it for vital functions. One very interesting fact is that vitamin B6 has many chemically similar forms. In vitamin supplements we frequently see the ‘pyridoxine’ form.
So what does the body use B6 for?
Part of many brain chemicals called neurotransmitters
Functions in amino acid metabolism
Functions in glucose metabolism
Functions in lipid metabolism
Helps your blood in making hemoglobin
It would be rare to get too much B6 from food sources and for food sources of B6 to lead to toxicity. The usual cause of B6 toxicity is taking too much B6 through over the counter supplements.
One really cool fact: syndrome of B6 toxicity mimics B6 deficiency.
The most common presentation is ‘numb feet’ or what is known as sensory neuropathy. If you catch it in time you can resolve the issue by stopping the B6 supplements.
The amount of B6 contained in a single ‘general’ multivitamin is usually safe and effective.
What happens if you take too much Vitamin A?
Nice chart from Toni Julian’s website about too much of a good thing can be toxic.
Referred to by experts as hypervitaminosis A, too much vitamin A can be toxic. Vitamin A is fat-soluble vitamin (DEAK are the fat soluble vitamins). In your body vitamin A is stored in the liver.
What foods contain vitamin A?
Egg yolks
meat
Fish
Poultry
Dairy
Vitamin A can be in some but not all fruits/vegetables
Where do people get into trouble with vitamin A? It is possible to get too much vitamin A from your diet, however most commonly too much vitamin A occurs as a result of taking too many supplements.
A not so fun fun fact is that if you take too much vitamin A in a single sitting (several hundred thousand units) you can become acutely ill.
Chronically, the toxicity is most associated with folks who take supplements of >25,000 IU a day. Remember also that skin creams with retinol can contribute to vitamin A toxicity issues.
What are the symptoms which may suggest possible vitamin A deficiency.?
Headaches
Nausea and in some cases vomiting
Blurry vision
Pain which may be different than typical pain and it may feel like it is coming from your bones
Changes in attentiveness or alertness
Changes in appetite (usually a decrease in hunger)
Lightheaded, dizzy or spinning sensations.
Longer term with vitamin A toxicity you may experience cracking in the lips and skin itching (and other skin symptoms).
The skin may turn yellow from the effects on the liver.
What issues can too much Vitamin E lead to?
fromgreens.com vitamin E toxicity nice pic in their write up.
Vitamin E is a lipid soluble antioxidant, so it must all be good, right? We rarely hear anything about vitamin E, however there is one issue we should all be aware of. Too much vitamin E can lead to serious bleeding. Occasionally, we have observed vitamin E toxicity cases where the bleeding occurs in the brain.
Here is a fun fact: There are ~8 different vitamin E compounds, however in humans the dominant one is alpha-tocopherol.
Beyond bleeding what are the other issues which can emerge with vitamin E toxicity?
Thyroid problems
Fatigue and subjectively feeling weak
Mood issues
Stomach problems
In some cases breast tenderness
Thrombophlebitis.
How do I treat Vitamin E Toxicity?
Stop taking excessive supplements with too much Vitamin E.
In emergency situations, we administer vitamin K therapy if there is a bleeding episode.
Can too muchVitamin D cause toxicity?
Great picture of vitamin D toxicity from verywellmind.
Vitamin D toxicity is almost always a result of taking supplements. Here is some great news: It is hard to become vitamin D toxic from diet or from sun exposure.
What do we worry about with vitamin D toxicity? Too much vitamin D will lead to too much calcium in the blood.
What are the common symptoms?
Nausea
Vomiting
Feeling weak or fatigued
Urinary frequency
Kidney stones
Possible pain (bone pain)
How do I treat Vitamin D toxicity?
Stop vitamin D and monitor the amount of calcium you get in your diet.
The U.S. Recommended Dietary Allowance (RDA) for vitamin D is 600 IU of vitamin D a day.
It is important to have your doctor or healthcare professional check a vitamin D level and make sure to replace if you are found to be deficient.
I am on dopamine replacement therapy, should I take a multivitamin?
Great article in Parkinsonism and Related Disorders 2023 by Eric Ahskog.
Levodopa, homocysteine and Parkinson’s disease: What’s the problem? This is a great article written by Eric Ahlskog at the Mayo Clinic in Rochestor Mn. Here are Eric’s main points.
Deficiency of vitamin B12, B6, and folate are all associated with high homocysteine blood levels.
B-vitamin deficiencies, especially B12 deficiency can lead to neuropathies (numb feet) and other neurological issues.
B12 laboratory levels can be low normal however you can still be deficient.
If you have a low normal B12, a ‘methylmalonic acid level’ can be checked and this level will be ‘up’ when B12 is deficient.
B-vitamins are important in the metabolic pathway that involves the enzyme COMT and may function as co-factors.
When you take levodopa it may deplete vitamins B12, folate, or deplete B6.
Levodopa increases homocysteine levels (the mechanism is through COMT).
High homocysteine can be associated with cognitive impairment.
Taking a balanced multivitamin can help you to avoid issues related to your Parkinson’s treatment.
If you have Parkinson’s, you should strongly consider taking just 1 multivitamin a day.
One multivitamin (pill, tablet or gummy) has everything you need to stay healthy and to avoid the effects of vitamin toxicity. Additionally, if you have Parkinson’s disease you are likely already on dopamine replacement therapy (or will be soon).
We now return to the thesis of the blog.
Take one multivitamin a day and this will help you to avoid the toxicity of multiple supplements, as high doses of vitamins can have serious adverse effects. Make sure your multivitamin contains folic acid, B12, and B6 which will address any deficiency issues you may encounter when also taking dopamine.
A few final tips:
Have your primary care doc or practitioner check your levels annually and re-dose or change dosing as appropriate. Avoid mega-dosing vitamins.
Do not take cyanocobalamin which is one of the forms of B12 if if you have kidney problems.
Do not take more than 25mg of vitamin B6.
Think of all the money you will save by simplifying your regimen to one multivitamin a day!
We should avoid mega-dosing of vitamins and here is a nice chart from dotfit on reasonable doses; and remember to have your primary care doc check levels.
Selected References:
Ahlskog JE. Levodopa, homocysteine and Parkinson's disease: What's the problem? Parkinsonism Relat Disord. 2023 Apr;109:105357. doi: 10.1016/j.parkreldis.2023.105357. Epub 2023 Mar 6. PMID: 36922273.
Rahnemayan S, Ahari SG, Rikhtegar R, Riyahifar S, Sanaie S. An umbrella review of systematic reviews with meta-analysis on the role of vitamins in Parkinson's disease. Acta Neurol Belg. 2023 Feb;123(1):69-83. doi: 10.1007/s13760-022-02055-3. Epub 2022 Aug 3. PMID: 35920987.
Rahnemayan S, Ahari SG, Rikhtegar R, Riyahifar S, Sanaie S. An umbrella review of systematic reviews with meta-analysis on the role of vitamins in Parkinson's disease. Acta Neurol Belg. 2023 Feb;123(1):69-83. doi: 10.1007/s13760-022-02055-3. Epub 2022 Aug 3. PMID: 35920987.
Michael Okun is one of the blog editors and also serves as the Medical Advisor for the Parkinson’s Foundation.
Jonny Acheson is our blog artist. He also is a medical doctor and has Parkinson’s.