Study finds link between low Vitamin D and heart disease, cancer, and all-cause mortality

A vast review of studies on Vitamin D has concluded that people with low levels of the vitamin had a 35 percent increased risk of death from heart disease, a 14 percent higher risk of death from cancer, and a greater risk of death from all causes as well.

The authors of this review, who came from a wide range of European and US universities, also looked at the usefulness of supplements, and found that there was no benefit from taking Vitamin D2. However, when they studied middle-aged and older adults who took Vitamin D3, they found an 11% reduction in risk of death from all causes. They also estimated that up to two-thirds of the people in Europe and the US are deficient in Vitamin D, and they calculated that about 13% of all deaths in the US, and about 9% of all deaths in Europe, are linked to low Vitamin D levels.

NYBC’s comment: This review suggests that it is crucial to supplement with Vitamin D3—-which is the type of Vitamin D stocked by NYBC. Older forms of supplementation, such as Vitamin D2-fortified milk, may not have benefit, according to this research. Secondly, though some have argued that low Vitamin D may simply be a side effect of disease processes that can’t be reversed by supplementing, we believe that this study also offers evidence that, especially when people are known to be deficient in Vitamin D (as is often the case in older populations, or among HIV+ people), supplementing with D3 has the potential to reduce disease risks, and indeed may reduce the overall risk of mortality.

See NYBC’s catalog for more detailed recommendations on Vitamin D3 supplementation:

Vitamins and Minerals – NYBC Catalog

Reference:

Chowdhury, R et al. Vitamin D and risk of cause specific death: systematic review and meta-analysis of observational cohort and randomised intervention studies. BMJ April 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g1903

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Higher Vitamin D levels linked to slower progression of Multiple Sclerosis

Patients with high vitamin D levels in the year after the first onset of multiple sclerosis demonstrated, over the next 4 years, much lower levels of MS disease and disability progression than those patients with lower levels of the vitamin. This was the conclusion of Harvard School of Public Health researchers who were following various treatment options for multiple sclerosis in a multi-year study.

The investigation, reported in the Journal of the American Medical Association – Neurology, elicited many comments from healthcare practitioners, mostly in support of adopting Vitamin D supplementation strategies for MS patients. (The research reported in JAMA Neurology did not involve supplementation, only looked at the association between various Vitamin D levels and disease progression.) Here’s one comment, from Marian Evatt, MD:

“This doesn’t surprise me — because of available data on MS and bone health, I’ve been trying to keep MS (and other neurology) patients at 30 ng/mL for a while. So this study won’t change what I do for MS patients. That said, I don’t know how well these kinds of findings have gotten out to the general practice community, so this adds to the body of evidence to support general neurologists and primary care physicians paying attention to vitamin D levels in patients with newly diagnosed MS. Compared with many of my neurology colleagues, I am relatively aggressive about keeping 25OH vitamin D levels replete because there’s plenty of evidence vitamin D interventions work for bone health and fall prevention (issues MS and other neurology patients commonly have).”

From: MedPage Neurology Friday Feedback: Vitamin D — the MS Magic Bullet? Published: Jan 24, 2014

Reference: Ascherio A, et al Vitamin D as an early predictor of multiple sclerosis activity and progression. JAMA Neurol 2014; DOI: 10.1001/jamaneurol.2013.5993.

Taking Vitamin D3 supplements for more than 3 years linked to lower mortality

We’ve heard a lot about Vitamin D in the past few years. There have been studies linking low Vitamin D levels to a host of health issues, from heightened risk of cardiovascular disease, to higher probability of developing the flu, especially during the winter season, when you get less exposure to the sunshine that allows the body to produce its own supply of the vitamin.

Now here’s an interesting meta-analysis (=review of previously published research) that looks at the connection between long-term use of Vitamin D3 supplements (“long-term” defined, in this case, as more than three years). Reviewing data from 42 earlier trials, this investigation found that those who supplemented with Vitamin D for longer than three years had a significant reduction in mortality. Specifically, this research found that the following groups showed a lower risk of death when supplementing with Vitamin D over a period longer than three years: women, people under the age of 80, those taking a daily dose of 800IU or less of Vitamin D, and those participants with vitamin D insufficiency (defined as a baseline 25-hydroxyvitamin D level less than 50 nmol/L).

Here’s the conclusion reached by the researchers:

The data suggest that supplementation of vitamin D is effective in preventing overall mortality in a long-term treatment, whereas it is not significantly effective in a treatment duration shorter than 3 years. Future studies are needed to identify the efficacy of vitamin D on specific mortality, such as cancer and cardiovascular disease mortality in a long-term treatment duration.

Our comment: We’re not surprised that supplementing over a period of years proves, in this review, to be more beneficial than briefer periods of supplementing. Vitamin D, like many supplements, shouldn’t be seen as treatment for an acute condition. It doesn’t act like an antibiotic, which may clear up an infection with a couple weeks of treatment. Instead, think of the body as having a long-term, continual need for Vitamin D; and note as well that seasonal change, or a particular health status (for example, being HIV+), may lead to deficiency and thus increase your need for supplementing. We were somewhat surprised to see that a significantly lowered risk of mortality was found even with a moderate rate of supplementation (800 IU daily dose). On this Blog you can read about other research that links decreased risk of flu, for example, with a daily Vitamin D dose of 2000IU. At any rate, there are no known “adverse events” at either of these doses of the vitamin, so not to worry, whether you’re following the lower or a higher recommendation.

See the NYBC catalog for Vitamin D3 offerings:

http://nybcsecure.org/index.php?cPath=25

Reference:
Zheng Y, et al. Meta-analysis of long-term vitamin D supplementation on overall mortality. PLoS One. 2013 Dec 3;8(12):e82109. doi: 10.1371/journal.pone.0082109.

Response to Annals Hysteria

Aside from the recent Times article that once again spread a message of fear and misinformation, three articles were published in the Annals of Internal Medicine that were accompanied by an editorial verging on hysteria that proclaimed in stentorious tones: DON’T TAKE THEM!

Is that a justifiable conclusion? Well, when you look at the studies undertaken, I don’t believe the answer is that clearcut.  However, there also may be evidence here that clarifies who may and may not benefit from a simple micronutrient supplement.  At the end of the article are links to other analyses that rebut the claims made.

Let’s take a little closer look at each of these three negative studies. First, one relatively large study, using a low dose combination of often synthetic vitamin constituents (Centrum Silver) among older individuals (1). Using these modest doses, the upshot of the study, which was otherwise well-controlled and randomized, found no benefit of the use of the supplement in offsetting or mitigating cognitive decline over about 10-14 years. This was part of the large physician’s study and the study was limited by the potential that the doses may have been too low for an otherwise well-nourished population. Is this generalizable to older individuals who are well-nourished?

Perhaps so and taking a Centrum is therefore quite probably a waste of money if maintaining cognitive function is the goal. However, this is the same study that had previously reported that even this simple intervention modestly reduced the risk of cancer. Is that a useful endpoint? And indeed, the authors note that the study may need to be up to 20 years or longer to adequately detect any significant differences.

The third study was a meta-analysis or review of the literature that has pre-specified criteria for the selection of studies to be reviewed and then applies stastical analytic techniques to combine the results into a conclusion (3). They sought to assess the use of multivitamins in the primary prevention of cancer or cardiovascular disease. (Drug studies indeed more commonly look at the use of a drug in preventing a second heart attack, for example: secondary prevention.) Having done these, I know there is a certain degree of judgment in what gets selected and the method used for analysis. In this case, the authors note that the primary limitations are as they note is 1) they only assessed four RCTs and one cohort study that used radically different multivitamin/mineral formulas; one of these was a study that used a multi with only 5 ingredients another only 3 vitamins; 2) these were ONLY among otherwise healthy adults (not secondary prevention studies). The PHS-II study, discussed above, and another the SU.VI.MAX study were the two largest studies. So what can we conclude from this? That the extant data do not robustly support the use of a multi for these indications? Possibly, though they also note that the large PHS-II study that found a benefit for reducing cancer risk also detected a benefit for fatal myocardial infarction (adjusted hazard ratio, 0.61 [95% CI, 0.38 to 0.995]; P < 0.048). It may again be that these interventions are not up to the rather daunting task of achieving the endpoint of primary prevention—such studies probably need to be larger and a lot longer to come up with definitive conclusions.

They also reviewed single and paired studies. They noted that calcium alone is ineffective overall and possibly dangerous as a single supplement, but you throw in vitamin D, and gosh–lower mortality, though just barely (unadjusted RR 0.94, 95%? CI 0.87,1.01). It begins to beggar the imagination however to think these extremely disparate trials can be combined in any meaningful way when the populations, interventions and even primary outcomes were so significantly different.

The third study, however, did assess the effects of chelation therapy, with or without a multivitamin/mineral combination as secondary prevention for a heart attack (myocardial infarction) (3). It was a relatively short study with a median follow-up of 31 months in the vitamin group. The article notes that there was a huge dropout rate. Of the 853 in the vitamin arm and the 855 in the placebo arm, 584 and 547 were lost to follow up, respectively but the analysis was done “intent-to-treat” and all were included in the final analysis. Further, the study was not powered to see a difference with the few that were finally enrolled and completed the study—i.e., the initial proposal was to enroll 2,372 patients. And there was a small difference: while the primary and secondary outcomes did not achieve statistical significance, one can see in the Kaplan-Meier curves that there is a lower rate of events in the multi arm compared to the control by about 11% and that appears to improve as the study progresses: had it lasted longer or been better powered, might this trend have improved over time? We don’t know. The effect is relatively modest but the study wasn’t powered to detect this difference.

It seems to me that the latter study reflects reality and should calm the anxieties about people using supplements expressed by the editors (4). The upshot: Most people don’t want to take vitamins as suggested by the Lamas study. If THAT conclusion is generalizable, they have little to fear—but is that wise public policy?

The other important fact to note was that all the studies showed no evidence of adverse events. For the most part, side effects of the use of supplements are exceedingly rare and generally arise with the use of single agents (e.g., vitamin E or beta-carotene alone). Probably not the wisest way to use interventions designed to work in a biological way or in a system that is severely oxidatively stressed.

I would suggest several caveats. First, this is irrelevant to people living with HIV. Even a fairly simple formula can have a significant impact in slowing disease progression and reducing mortality (modestly) with the use of a multivitamin/mineral. The results of our meta-analysis will, we hope, be published soon. (This of course does NOT mean they are a replacement for antiretroviral therapy! Absolutely not.)

Second, these are SUPPLEMENTS – diet and access to clean water need to be the first consideration and far too many people have limited access to these basics while millions of others are forced to consume what is available on the market, which is often poor quality, processed, loaded with chemicals, preservatives, antibiotics, hormones and potentially dangerously genetically modified.

And finally, supplements are NOT drugs in key ways. They are supporting the body’s ability to fight disease while retaining an optimal level of health, especially when we are discussing the use of vitamins and minerals (as opposed to botanicals). Whether the optimal dosages have been determined, whether the findings are generalizable to everyone, whether there are groups, like people with HIV, for whom they are demonstrably beneficial—these are questions hardly answered to the point of declaring no one should ever use them as these editors have done.

Links:

Harvard rebuts the Annals of Internal Drugs.

http://www.hsph.harvard.edu/nutritionsource/multivitamin/

Linus Pauling Institute of Oregon State University.

http://lpi.oregonstate.edu/news/enoughisenough-response.html

Michael Mooney’s overview:

http://www.michaelmooney.net/Erroneous_Annals_Of_Internal_Medicine_Study_Says_Vitamins_Don%27t_Work.html

Industry’s Council for Responsible Nutrition:

http://www.nutraceuticalsworld.com/contents/view_blog/2013-12-18/enough-is-enough/?email_uid=dee72d271a/list_id=396c189146/

Michael Murray, ND:

http://doctormurray.com/?utm_source=WOW+-+Editorial+in+Medical+Journal+Promotes+Propaganda+Against+Multiple+Vitamin+&utm_campaign=CCmailing6-12-13&utm_medium=email

References:

1. Grodstein F, O’Brien J, Kang JH, et al. Long-Term Multivitamin Supplementation and Cognitive Function in Men: The Physicians’ Health Study II. Annals of Internal Medicine. 2013;159(12) :806-814-814. doi: 10.7326/0003-4819-159-12-201312170-00006.

2. Fortmann SP, Burda BU, Senger CA, Lin JS, Whitlock EP. Vitamin and Mineral Supplements in the Primary Prevention of Cardiovascular Disease and Cancer: An Updated Systematic Evidence Review for the U.S. Preventive Services Task Force. Ann Intern Med. Nov 12 2013;159(12):824-834-834. doi: 10.7326/0003-4819-159-12-201312170-00729.

3. Lamas GA, Boineau R, Goertz C, et al. Oral High-Dose Multivitamins and Minerals After Myocardial Infarction. Annals of Internal Medicine. 2013;159(12):797-805-805. doi: 10.7326/0003-4819-159-12-201312170-00004.

4. Guallar E, et al. Enough Is Enough: Stop Wasting Money on Vitamin and Mineral Supplements. Ann Intern Med. 2013;159(12): 850. Retrieved 19 Dec 2013 from http://annals.org/article.aspx?articleid=1789253

Why Vitamins B12 and D3 Are Especially Important to People with HIV

Our friends at the Canadian AIDS Treatment Information Exchange (CATIE), a Canadian government-supported education and prevention organization, recently published an excellent guide to managing HIV medication side effects. This online guide covers the territory from body shape changes, to gastrointestinal disorders, to neurological effects, to emotional wellness, to fatigue, to sexual difficulties.

The Appendix to this guide focuses on two vitamins, both of which have been highlighted as especially important for people with HIV: B12 and D3. Deficiency of these two vitamins appears to be common among people with HIV, and supplementing to correct the deficiency can bring about major improvements in health. So it’s definitely worthwhile to check your B12 and D3 status, and, if you’re deficient, find a good supplementation strategy. Note that NYBC stocks both of these inexpensive vitamins: the methylcobalamin form of Vitamin B12 recommended below; and several strengths of Vitamin D3, including the commonly recommended D3 – 2500IU format.

Below are the CATIE recommendations:

Vitamin B12

A number of studies have shown that vitamin B12 is deficient in a large percentage of people with HIV, and the deficiency can begin early in the disease. Vitamin B12 deficiency can result in neurologic symptoms — for example, numbness, tingling and loss of dexterity — and the deterioration of mental function, which causes symptoms such as foggy thinking, memory loss, confusion, disorientation, depression, irrational anger and paranoia. Deficiency can also cause anemia. (See the section on Fatigue for more discussion of anemia.) It has also been linked to lower production of the hormone melatonin, which can affect the wake-sleep cycle.

If you have developed any of the emotional or mental symptoms mentioned above, especially combined with chronic fatigue, vitamin B12 deficiency could be contributing. This is especially true if you also have other symptoms that this deficiency can cause, including neuropathy, weakness and difficulty with balance or walking. On the other hand, these symptoms can also be associated with HIV itself, with hypothyroidism or advanced cases of syphilis called neurosyphilis. A thorough workup for all potential diagnoses is key to determining the cause.

Research at Yale University has shown that the standard blood test for vitamin B12 deficiency is not always reliable. Some people who appear to have “normal” blood levels are actually deficient, and could potentially benefit from supplementation.

The dose of vitamin B12 required varies from individual to individual and working with a doctor or naturopathic doctor to determine the correct dose is recommended. Vitamin B12 can be taken orally, by nasal gel or by injection. The best way to take it depends on the underlying cause of the deficiency, so it’s important to be properly assessed before starting supplements. For oral therapy, a typical recommendation is 1,000 to 2,000 mcg daily.

One way to know if supplementation can help you is to do a trial run of vitamin B12 supplementation for at least six to eight weeks. If you are using pills or sublingual lozenges, the most useful form of vitamin B12 is methylcobalamin. Talk to your doctor before starting any new supplement to make sure it is safe for you.

Some people will see improvements after a few days of taking vitamin B12 and may do well taking it in a tablet or lozenge that goes under the tongue. Others will need several months to see results and may need nasal gel or injections for the best improvements. For many people, supplementation has been a very important part of an approach to resolving mental and emotional problems.

Vitamin D

Some studies show that vitamin D deficiency, and often quite severe deficiency, is a common problem in people with HIV. Vitamin D is intimately linked with calcium levels, and deficiency has been linked to a number of health problems, including bone problems, depression, sleep problems, peripheral neuropathy, joint and muscle pain and muscle weakness. It is worth noting that in many of these cases there is a link between vitamin D and the health condition, but it is not certain that a lack of vitamin D causes the health problem.

A blood test can determine whether or not you are deficient in vitamin D. If you are taking vitamin D, the test will show whether you are taking a proper dose for health, while avoiding any risk of taking an amount that could be toxic (although research has shown that toxicity is highly unlikely, even in doses up to 10,000 IU daily when done under medical supervision). The cost of the test may not be covered by all provincial or territorial healthcare plans or may be covered only in certain situations. Check with your doctor for availability in your region.

The best test for vitamin D is the 25-hydroxyvitamin D blood test. There is some debate about the best levels of vitamin D, but most experts believe that the minimum value for health is between 50 and 75 nmol/l. Many people use supplements to boost their levels to more than 100 nmol/l.

While sunlight and fortified foods are two possible sources of vitamin D, the surest way to get adequate levels of this vitamin is by taking a supplement. The best dose to take depends on the person. A daily dose of 1,000 to 2,000 IU is common, but your doctor may recommend a lower or higher dose for you, depending on the level of vitamin D in your blood and any health conditions you might have. People should not take more than 4,000 IU per day without letting their doctor know. Look for the D3 form of the vitamin rather than the D2 form. Vitamin D3 is the active form of the vitamin and there is some evidence that people with HIV have difficulty converting vitamin D2 to vitamin D3. Historically, vitamin D3 supplements are less commonly associated with reports of toxicity than the D2 form.

It is best to do a baseline test so you know your initial level of vitamin D. Then, have regular follow-up tests to see if supplementation has gotten you to an optimal level and that you are not taking too much. Regular testing is the only way to be sure you attain — and then maintain — the optimal level for health.

With proper supplementation, problems caused by vitamin D deficiency can usually be efficiently reversed.

Who’s Afraid of Cold and Flu Season? Not NYBC!

As the days get shorter and we approach the end of October, here in the Northern Hemisphere many worry about the Cold and Flu Season. Colds and flus aren’t fun for anyone, and people with compromised immune systems may be especially vulnerable. Here are some recommendations from NYBC, both in the prevention department and in the symptom alleviation department. Using these supplements, we believe, can make the Cold and Flu Season a lot less scary!

Vitamin D. According to some recent thinking, the “cold and flu season” may actually be the “Vitamin D deficiency season.” As the days grow shorter, people get less sunshine, leading to a decline in the body’s levels of this vitamin, which is essential to good health in many more ways than we used to think. Taking Vitamin D during the winter may therefore be one of the most effective ways to prevent colds and flu. Many researchers who’ve studied Vitamin D now recommend at least 2000 IU/day, but those with a known deficiency may be advised to supplement at even higher levels. There’s a simple test available to check for Vitamin D deficiency – ask your doctor.

Cold Away. This blend of Chinese herbs from Health Concerns is designed to “clear external heat and alleviate symptoms of the common cold.” A key component of this formula is the herb andrographis, which in several recent US studies was found to significantly decrease cold symptoms and the duration of a cold; it may also be useful for prevention. (NYBC stocks over 20 varieties of Traditional Chinese Medicine formulas, by the way.)

Vitamin C. Many good studies have shown a decrease in cold symptom duration, but no benefit for prevention. According to a guide to natural products published by the American Pharmacists’ Association in 2006, taking between one and three grams of Vitamin C per day may decrease cold symptoms (sore throat, fatigue, runny nose) by one to 1½ days.*

N-acetylcysteine (NAC) supports respiratory and immune system function. It has been studied extensively for chronic bronchitis. NAC is also the antidote for acetaminophen poisoning, now the leading cause of liver disease in the US. (Acetaminophen’s best-known tradename is Tylenol®, but it’s also found in many other drugs, so it’s become all too easy to overdose–especially when you’re fighting cold or flu symptoms.)

One popular way to take NAC is to use PharmaNAC, notable for its careful quality control, pleasant “wildberry” flavor, and effervescent fizz!

Botanicals. In Traditional Chinese Medicine, astragalus is used for chronic respiratory infections, for colds and flu (both prevention and treatment) and for stress and fatigue. It contains complex sugar molecules called polysaccharides, which some studies show stimulate virus-fighting cells in the immune system. Researchers at the University of Texas and M.D. Anderson Cancer Center have turned up evidence that astragalus boosts immune responses in lab animals, and in human cells in lab dishes.

Probiotics. They say the best defense is a good offense, so consider upping your intake of the beneficial bacteria found naturally in such things as kefir (the lightly fermented milk beverage) and yogurt: they boost the flora in your intestinal tract, which is where an estimated 80% your immune system resides. Also note that NYBC stocks several varieties of probiotic supplements, including Jarrow’s Ultra Jarro-Dophilus, which has helped many maintain healthy digestive function, always a key to getting proper nutrition into your system and thus supporting immune strength.

And this just in: See posts on this blog for Beta Glucan, which, according to very recent research reports, may be of substantial benefit for fighting colds.

*Natural Products: A Case-Based Approach for Health Care Professionals, ed. Karen Shapiro. Washington, DC: American Pharmacists’ Assoc. (2006), “Cold and Flu,” pp. 173-192.

Vitamin D may lower blood pressure in African-Americans

A trial published in the journal Hypertension (Feb 3, 2013) found that Vitamin D supplementation can lower blood pressure in African-Americans, who are at greater risk for high blood pressure than the general population.

In the research study, participants received a placebo, or 1000, or 2000, or 4000 IUs of Vitamin D3 a day for three months. There was no significant change for those taking the placebo. Those who took the highest amount of Vitamin D daily showed the greatest reduction in blood pressure. “This degree of blood pressure reduction, if confirmed in future studies, would be considered clinically significant,” said the lead author, Dr. John P. Forman. (Quoted in NYT online, where we first read of this story.)

NYBC stocks Vitamin D in several different strengths:

http://nybcsecure.org/index.php?cPath=25

Vitamin D is a low-cost supplement, and is reported to have no adverse effects in daily doses as high as 4000IU. Search under Vitamin D for previous posts on this blog about the vitamin’s potential for cardiovascular health benefits, especially for African-Americans and other groups at elevated risk.