News about Niacin

You may have read worried news reports earlier this year about a study of niacin + a statin drug used to lower cholesterol (lipids). The study was stopped prematurely because researchers detected a small increase in strokes among participants taking the niacin +simvastatin (Zocor) combination. This was quite a surprise to scientists, because niacin (a B-vitamin) has a 50-year history of safe and effective use for normalizing lipid levels, and the suggestion that a statin drug/niacin combination might carry even a slight extra cardiovascular risk was disturbing.

We were therefore glad to see the Canadian AIDS Treatment Information Exchange (CATIE) review and clarify the results of this study, while at the same time reporting on an important new piece of research about niacin, lipid control, and HIV. (You can find the full CATIE reporting about niacin at www.catie.ca.) CATIE’s view, in line with other cautionary voices, stresses that the niacin/statin study data do not show any clear connection between niacin and increased strokes. And it’s also true that, through 50 years of research on niacin and lipids, there’s never been any evidence of such a connection. In short: expect more examination of the issue, but don’t jump to any conclusions—there’s just not the evidence to support dropping niacin for lipid control.

Coincidentally, as the niacin/statin study was being suspended, results of another trial involving niacin for lipid control were being published. This research, conducted at Baylor College of Medicine in Texas, looked at a combination of niacin, fenofibrate (a prescription drug used to lower cholesterol), diet and exercise for lipid management among people with HIV. Called the Heart Positive study, this investigation found that a combination of high-dose niacin, together with fenofibrate, diet and exercise was clearly the best strategy for managing lipids in a group of more than 100 people with HIV. And, significantly–there were no signs in this research that niacin was unsafe.

We certainly urge all our members who use or are thinking of using niacin as part of a strategy to control lipids to talk to their doctors about the recent research. (You may even want to share the CATIE info with your physician.) As we’ve said above, we don’t see clear evidence that niacin poses extra, unexpected risks. Meanwhile, its benefits continue to be documented in research like the Heart Positive study. As always, we need to keep up with research news—and also maintain a bit of skepticism in judging how that news gets reported.

For more information on Niacin, see the NYBC entries:

Niatab 100/500mg

or the lower, starter dose:

Niacin 100/100mg

Vitamin D reduces cardiovascular risk for people with HIV

Still more evidence of how important it is for people with HIV to monitor their Vitamin D status and supplement to make up for insufficiency of the vitamin. This time it’s a connection between low levels of D and higher cardiovascular risk–risk of heart attack or stroke down the road. Note that people with HIV treated with a non-nucleoside reverse transcriptase inhibitor were more likely to be Vitamin D deficient. And note as well the findings–similar to those of other studies–that African-Americans and people with higher Body Mass Index are more likely to be deficient in D.

See NYBC’s store for very low-cost Vitamin D at the most frequently recommended dosages: http://nybcsecure.org/

Investigators from the University of California-San Francisco Study of the Consequences of the Protease Inhibitor Era cohort […] sought to establish the prevalence and risk factors for low vitamin D levels in patients with HIV, and the relationship between vitamin D deficiency and sub-clinical atherosclerosis (hardening of the arteries), measured by cIMT.

Their cross-sectional, or “snap-shot” study involved 139 patients, whose average age was 45. The majority (84%) were male, 54% were white and 32% were black. Three-quarters of patients were taking antiretroviral therapy and 71% of these individuals had a viral load below 1000 copies/ml. The median CD4 cell count was 336 cells/mm3.

Between a fifth and a third of patients had traditional risk factors for cardiovascular disease such as smoking, high blood pressure, or elevated cholesterol.

Over half (52%) of patients had vitamin D deficiency (below 30 ng/ml). Factors associated with insufficient levels of the vitamin included black race (relative risk [RR] = 2.62; 95% CI, 1.80-3.82) and a higher body mass index, or BMI (RR = 1.25 per BMI increase of 5; 95% CI, 1.03-1.51). Both of these risk factors have been observed in other research.

Taking vitamin D supplements reduced the risk of insufficiency by almost a third (RR = 0.70; 95% CI, 0.52-0.95).

During the first six months of HIV therapy, patients treated with a non-nucleoside reverse transcriptase inhibitor (NNRTI) were 2.5 times more likely than patients taking a protease inhibitor to have low levels of vitamin D. The investigators call for this finding “to be re-evaluated in other cohorts with longer NNRTI exposure.”

FROM: http://www.aidsmap.com/page/1750226/

Acetylcarnitine for cardiovascular health

Acetylcarnitine (or acetyl-l-carnitine) has been studied in recent years for its neuroprotective effects. It is the subject, for example, of some good research on peripheral neuropathy (nerve damage leading to tingling, pain in the hands and feet) in people with HIV.

But we were interested to read about a 2009 report on acetylcarnitine used in a pilot study of people with elevated cardiovascular disease risk. The investigation, which involved 24 weeks of oral acetylcarnitine therapy (1 gram daily), found significant improvement in high blood pressure and glucose control among the study subjects. Since these improvements point to a decrease in cardiovascular disease risk, the investigators suggest that further research be done to see whether long-term acetylcarnitine supplementation can be a good cardioprotective strategy.

Here’s the abstract of the article:

Ameliorating Hypertension and Insulin Resistance in Subjects at Increased Cardiovascular Risk
Effects of Acetyl-L-Carnitine Therapy
Piero Ruggenenti; Dario Cattaneo; Giacomina Loriga; Franca Ledda; Nicola Motterlini; Giulia Gherardi; Silvia Orisio; Giuseppe Remuzzi

From the Unit of Nephrology (P.R., G.R.), Azienda Ospedaliera Ospedali Riuniti, Bergamo, Italy; Clinical Research Center for Rare Diseases “Aldo and Cele Daccò” (P.R., D.C., G.L., F.L., N.M., G.G., S.O., G.R.), Mario Negri Institute for Pharmacological Research, Bergamo, Italy; Institute of Special Medical Pathology (G.L., F.L.), Università degli Studi, Sassari, Italy.

Correspondence to Giuseppe Remuzzi, Mario Negri Institute for Pharmacological Research, Via Gavazzeni 11, 24125 Bergamo, Italy. E-mail gremuzzi@marionegri.it

Insulin resistance, a key component of the metabolic syndrome, is a risk factor for diabetes mellitus and cardiovascular disease. Acetyl-L-carnitine infusion acutely ameliorated insulin sensitivity in type 2 diabetics with insulin resistance. In this sequential off-on-off pilot study, we prospectively evaluated the effects of 24-week oral acetyl-L-carnitine (1 g twice daily) therapy on the glucose disposal rate (GDR), assessed by hyperinsulinemic euglycemic clamps, and components of the metabolic syndrome in nondiabetic subjects at increased cardiovascular risk a priori segregated into 2 groups with GDR 7.9 (n=16) or >7.9 (n=16) mg/kg per minute, respectively. Baseline GDR and systolic blood pressure were negatively correlated (n=32; P=0.001; r=–0.545), and patients with GDR 7.9 mg/kg per minute had higher systolic/diastolic blood pressure than those with higher GDR. Acetyl-L-carnitine increased GDR from 4.89±1.47 to 6.72±3.12 mg/kg per minute (P=0.003, Bonferroni-adjusted) and improved glucose tolerance in patients with GDR 7.9 mg/kg per minute, whereas it had no effects in those with higher GDRs. Changes in GDR were significantly different between groups (P=0.017, ANCOVA). Systolic blood pressure decreased from 144.0±13.6 to 135.1±8.4 mm Hg and from 130.8±12.4 to 123.8±10.8 mm Hg in the lower and higher GDR groups, respectively (P<0.05 for both; P<0.001 overall) and progressively recovered toward baseline over 8 weeks posttreatment. Total and high molecular weight adiponectin levels followed specular trends. Diastolic blood pressure significantly decreased only in those with higher GDRs. Treatment was well tolerated in all of the patients. Acetyl-L-carnitine safely ameliorated arterial hypertension, insulin resistance, impaired glucose tolerance, and hypoadiponectinemia in subjects at increased cardiovascular risk. Whether these effects may translate into long-term cardioprotection is worth investigating.

See the NYBC entry on acetylcarnitine for further information:
http://nybcsecure.org/product_info.php?products_id=118

and acetylcarnitine/Biosint (Italian source):
http://nybcsecure.org/product_info.php?cPath=50&products_id=320

Low Vitamin D linked to high rates of death from heart disease or stroke

An article in the American Journal of Epidemiology, October 15, 2009 found that low vitamin D levels are linked to higher rates of death from heart disease or stroke.

The study was a long-term look at the health of 2,817 men and 3,402 women in Finland. At the beginning of the study period, participants were 49 years old on average and had no indicators of cardiovascular disease. They were followed for an avergae of 27 years, during which time 640 of the participants (358 of them men) died from heart disease and another 293 (122 of them men) died from stroke.

Those with the lowest blood levels of Vitamin D had a 25 percent higher risk of dying from heart disease or stroke when compared to the group with the highest blood levels of Vitamin D.

There was an especially notable link between vitamin D levels and stroke deaths, according to the Finnish researchers, in that having the lowest vitamin D seemed to confer about twice the risk stroke death, compared with having the highest vitamin D.

This study, we believe, provides still more evidence of the importance of assessing Vitamin D deficiency, and counteracting deficiency with remedies such as supplementing. Vitamin D is very inexpensive and has a well-characterized safety profile, so a simple supplementation strategy could have a major impact on long-term health.

Diet and depression — a follow-up note

In the Summer 2009 SUPPLEMENT, our feature story was entitled “Are You Ready to Join the Food Revolution?” The article referred to recent research highlighting a relationship between traditional diets, such as the Mediterranean or Chinese diet, and lower risk of certain cancers, heart disease, and even depression. So we were interested to read in our hometown newspaper The New York Times about a new report of findings about the health benefits of the Mediterranean diet. A large-scale epidemiological study in Spain again showed an association between the traditional Mediterranean diet and lower rates of mental health conditions like depression. Very interesting as well is this line of thinking from one of the researchers about why this diet should be linked to lower risk of both cardiovascular disease and depression:

Both cardiovascular disease and depression share “common mechanisms related to endothelium function and inflammation,” said Dr. Miguel Angel Martinez-Gonzalez, professor of preventive medicine at University of Navarra in Pamplona, Spain, and senior author of the paper, published in the October issue of Archives of General Psychiatry.

“The membranes of our neurons are composed of fat, so the quality of fat that you are eating definitely has an influence on the quality of the neuron membranes, and the body’s synthesis of neurotransmitters is dependent on the vitamins you’re eating,” Dr. Martinez-Gonzalez added. “We think those with lowest adherence to the Mediterranean dietary plan have a deficiency of essential nutrients.”

The elements of the diet most closely linked to a lower risk of depression were fruits and nuts, legumes and a high ratio of monounsaturated to saturated fats, the study found.

From:

http://www.nytimes.com/2009/10/13/health/research/13nutrition.html?scp=1&sq=Mediterranean%20diet&st=cse

“Good Fats/Bad Fats”: new dietary recommendations for supporting heart health and reducing cardiovascular risk

We were interested to read the Personal Health column by Jane Brody in the New York Times earlier this month. The article was entitled New Thinking About How to Protect the Heart, but you might also give this advice column on cardiovascular health the title of “Good Fats/Bad Fats.”

The main reason for revisiting diet recommendations for people trying to reduce their risk of heart attack is a new focus on the importance of inflammation in assessing cardiovascular risk. It’s been found, for example, that even people with normal cholesterol levels have a heightened risk of heart attack if they have a high reading of C-reactive protein (CRP), a marker of inflammation that correlates with clots that block blood flow to the heart.

So, if it’s not just cholesterol levels that people should be watching in order to minimize cardiovascular risk, what kind of diet should they be following to support a healthy heart? The short answer is not entirely new: it’s the Mediterranean diet, which actually turns out to be quite high in fats–think olive oil, oily fish, nuts, seeds and certain vegetables. It’s just that these are sources of “good fats”–not the heart-unfriendly saturated fats (=solid at room temperature) derived from red meats and cheese. And guess what? These “good fats” are found not only to lower cholesterol ratios, but also to decrease inflammation levels.

Recent studies, from the last 10 years or so, are pretty clear in showing the value of the Mediterranean diet, which is not only tasty and easy to follow for most people, but also appears to reduce the rates of heart disease recurrence and cardiac death by 50 to 70%.

As cardiovascular research sorted out the role of inflammation markers and the good fat/bad fat distinction, there also emerged a better understanding of the potential of supplements to maintain heart health. Fish oil, with its heart-healthy omega-3 fatty acids, is now widely recognized as a useful supplement for reducing cardiovascular risk. Other supplements, which incorporate elements of the Mediterranenan diet (such as olives), have also become available.

Here are a few entries from the NYBC catalog that are of special interest for this discussion:

Fatty Acids (see especially MaxDHA, and the ProOmega fish oil supplements)

C-1000 Ascorbic Acid plus Olea Fruit Extract This Vitamin C supplement from Jarrow has been enriched with an olive extract in a combination designed to support cardiovascular health.

Nutritional supplements to reduce cardiovascular risk

Here’s an excerpt from the Fall 2008 issue of the New York Buyers’ Club SUPPLEMENT . (You can read the full issue online at http://www.newyorkbuyersclub.org/supplement/, where you’ll also find an archive of past numbers.)

It’s all about managing risk.

People try to control risk all the time, whether it’s kids learning to cross the street on green, people buckling their seat belts when getting into the car, or a smoker looking at the statistics relating tobacco use to cancer and heart disease and deciding that now is the time to quit.

Earlier this year, a group of experts on HIV and heart disease recommended that people with HIV pay special attention to monitoring and controlling cardiovascular risk factors like high cholesterol and diabetes. Overall, according to currently available evidence, the risk of heart attack is approximately 70% to 80% higher for HIV-positive people than for HIV-negative people. This increased level of risk is likely due in part to HIV itself, and in part to HIV medications. Some typical cardiovascular warning signs for people with HIV include reduced levels of HDL (“good cholesterol”) and high triglycerides, or a tendency toward pre-diabetes. The panel of experts, which was convened by the American Heart Association and the American Academy of HIV Medicine, found indications that even HIV+ children on meds have early development of these kinds of cardiovascular risk factors.

You may also have heard recent news stories about the HIV medication abacavir and elevated risk of heart attack. A commonly used HIV med in the family of drugs called nucleoside analogs (“nukes”), abacavir is part of the combination drugs Ziagen and Trizivir. Two studies based on large databases have detected an association between abacavir and increased risk of heart attack. Although there isn’t an exact understanding of how abacavir (or another nuke, ddI) could cause higher risk of heart attack, the research does suggest that people with other cardiovascular risk factors, such as smoking or high cholesterol, are at the greatest risk.

Which brings us back to our original point: it’s all about managing risk—knowing the risk factors, then lowering them as much as you can. And that’s where nutritional supplements can be helpful.
At the top of the list of supplements to support cardiovascular health is fish oil, with its key component being the omega-3 fatty acids. Since 2005, the American Heart Association, following a hefty accumulation of scientific evidence, has recommended daily intake of fish oil for people with cardiovascular disease. And there has been research specifically looking at fish oil for people with HIV who have elevated cardiovascular risk. For example, a 2007 study of HIV+ people who had high triglyceride levels found that fish oil supplementation reduced these levels by 25% or more. Also of note: fish oil supplementation for people with HIV is being studied in federally funded research that examines how this supplement might counter the effects of lipodystrophy, a syndrome that includes blood lipid abnormalities.

People with HIV are often prescribed statin drugs like Lipitor to lower cholesterol and reduce cardiovascular risk, and while these drugs can be effective, they may also produce side effects, including joint and muscle pain and changes in mood and thinking ability. Many integrative health specialists endorse the idea of taking the supplement CoQ10 along with statins, since depletion of this nutrient by statins may be linked to some of the drug’s major side effects. Moreover, research suggests that, due to its antioxidant and blood-thinning properties, CoQ10 when combined with a statin decreases heart disease risk more than just the statin alone. Similarly, there is important research indicating that statins together with niacin can be more effective at reducing cardiovascular risk over the long term than just the statins. Though niacin dosage may have to be slowly increased in order to avoid “flushing” (redness, itchiness), strong scientific evidence for this supplement’s effectiveness and safety dates back to the 1970s, and indicates that it may be especially helpful in bringing up levels of HDL (“good cholesterol”), which is now regarded as a very significant marker for assessing cardiovascular risk.

A few months ago we were impressed by a talk given by Dr Jon Kaiser, an HIV physician with extensive experience in integrating nutrition and nutritional supplementation into his health care practice. While Dr. Kaiser ranged over several topics, including his well-known interest in the benefits of general micronutrient support for people with HIV, he also had much to say about controlling cholesterol levels with nutritional supplements. His approach consists of low-dose niacin (low dose to minimize flushing), fish oil, plant sterols and pantethine. As he’s started to follow case histories over the past few years, he’s become quite encouraged by the results, and believes that many people with HIV could achieve good results (comparable to those offered by statins, but without the side effects) by adopting this kind of combination therapy.

In the past year, NYBC has begun stocking a Douglas Labs product called CardioEdge, which, like Dr Kaiser’s approach, involves a combination of supplements (including plant sterols) to manage cholesterol. We’ve also recently added a Jarrow product, Pressure Optimizer, which combines several supplements (including theanine from green tea) that are useful in maintaining normal blood pressure. (High blood pressure is a major risk factor for cardiovascular disease, and it’s one of the first issues anyone should address in bringing down heart attack risk.)

We find that physicians who are knowledgeable about nutrition and nutritional supplements have a lot of useful advice to offer when it comes to controlling cardiovascular risk. For example, Dr Hyla Cass, author of the book Supplement Your Prescription: What Your Doctor Doesn’t Know About Nutrition (recently reviewed on the NYBC blog), calls attention to the fact that metformin, the most frequently prescribed diabetes drug in the US, depletes the B vitamins and thus can cause a spike in the body’s levels of homocysteine, a substance linked in recent research to high cardiovascular risk. To counter this danger, she emphasizes the need to supplement with B vitamins when taking metformin.

In line with much current scientific thinking, Dr Cass also believes that cholesterol level by itself is not an adequate measure for assessing cardiovascular risk. In addition, it’s necessary to look at underlying inflammatory processes in order to comprehend the threats to heart and circulatory system health. That’s why Dr. Cass recommends that people who want to reduce their risk of cardiovascular disease should develop a diet plan centering on anti-inflammatory nutrients. She suggests a diet high in antioxidant-rich foods—colorful fruits and vegetables, curry, rosemary, ginger, green tea, dark chocolate, and low-toxin fish like salmon or sardines. (Actually could make for quite a tasty menu, don’t you think?)

To conclude: yes, it’s sobering when researchers warn about increased cardiovascular risk for people with HIV. But there’s also general agreement that cardiovascular risk is very susceptible to management by choices in diet and nutrition. (Exercise and quitting smoking are also important!) So, while you can’t control everything in life, remember that there are many choices you can make to significantly reduce your cardiovascular risk.

Nutritional supplements discussed in this article: fish oil, CoQ10, niacin, plant sterols, pantethine, B vitamins; and the proprietary formulas CardioEdge and Pressure Optimizer.