Vitamin Drinks Risk Serious Harm


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Are Vitamin Drinks a Bad Idea?

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from New York Times

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Free full report below

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I need time to write about so many exciting things I am seeing in my practice, but this is always lurking. Children and athletes are at most risk for growing toxicity from overdosing on supplements. This has yet to be studied. Not just from vitamin drinks but daily vitamins pills too.

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IV Infusion clinics are the rage now popping up all over London. The very luxurious price alone would convince most people that the more they pay, the better it feels. Did it begin in Hollywood? Surely La Jolla will be soon.

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I see so much of the excess. My thoughts are often on the harm of vitamins and supplements and I’ve posted here, here, here, here, here, here, here, here, here, here about their risk to brain, peripheral nerves, heart, hypertension, cancer, interference with chemotherapy and cardiovascular medications, and in some cases risk to every cell of the entire body.

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$18 Billion a year business in the U.S

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This is an $18 billion a year business in the U.S. which explains why, since the 1970’s, Congress shot down the FDA’s authority to regulate dietary supplements and nutrients that could be fortified. Of course, congress restricts and excludes trade of European supplements that have proven scientific value. Usually this would be called unfair trade, but ….

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Forgive me for being superfluous to point out that those who bring in one bottle with 30 ingredients astonishes me. Centrum Silver I’m thinking of you. How much titanium, molybdenum, chromium and zinc do we need every day to go with its toxic doses of B6 and the proven harmful Vitamins A and E? What is so completely lacking in the diet? How easy is this on seniors with reduced capacity to metabolize medications? No studies, thanks.

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I favor several important vitamins for key reasons based on blood work, but known essential supplements seem to lost on many. Zinc is everywhere. This is rarely tested in a patient. Who has ever once tested most things in Centrum Silver? Could the popularity be due to bombardment or with unproven labeling or endless aisles of bottles?

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This is a rich person’s game.Typically female, unless guys are hiding or avoiding them.

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There are those who drag behind them truck loads of large suitcases bursting with expensive supplements. They need to stop the cause of their problems that is in those bags. They may link bags together with cabling like a train or walk back several times to pull in more and more.

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Stop all of them. That is the treatment. That and a long, long drug holiday to wash them out of the system. Eat a basic healthy diet in moderation and always exercise. There is then hope to re-establish equilibrium. Who could swallow that many pills every day and have any room left for food?

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But I digress.

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The Report – free full text.

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An examination of the nutrient content and

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on-package marketing of novel beverages.

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Risks

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46 novel beverages tested

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“there is little evidence that consumers stand to benefit

from the micronutrients most commonly found in these products.”

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But aiyee!!! the problems.

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At long last, after billions spent on vitamin drinks, the risks are addressed by Valerie Tarasuk, lead author of the study. She is nutrition science professor at the University of Toronto faculty of medicine. I quote extensively from the New York Times but recommend the entire article.

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“A nationwide study carried out by the National Institutes of Health in 2012 found that Americans who take vitamins and supplements were already getting large amounts of nutrients from their food, and on top of that they had the lowest prevalence of vitamin deficiencies to begin with. The study found that supplement use put these people at increased risk of potentially excessive consumption of folic acid, calcium, iron, zinc, magnesium and vitamins A, C and B6.”

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 “…for much of the general population today, there is no scientific justification for a high intake of vitamins and minerals, said Mara Z. Vitolins, a registered dietitian and professor of epidemiology and prevention at Wake Forest Baptist Medical Center.”

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“When consumed in excess, some water-soluble vitamins like B and C are excreted in the urine [unless toxic to nerves and kidneys, those of you who develop nerve pain and kidney stones from them]. But fat soluble-vitamins – including A, D, E and K – accumulate in tissues, posing potential risks.”

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“These fat soluble vitamins are very stable,” she said. “They’re not released in the urine. If you are over-consuming them, you can raise your levels gradually over time and get into trouble with liver function. You have to be very careful with them.”

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Authors should warn be even more cautious when you lose weight, the fat and that giant stash must somehow get out or what harm will they all cause next?

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“Data from clinical trials have highlighted clear risks from excess. A large study published in JAMA in 2009, for example, looked at clinical trial data on more than 6,000 heart disease patients who were treated daily with either B vitamins or placebo over a seven year period. The study found that those who were given folic acid and B12 had higher mortality and cancer rates.”

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“In 2012, a review of 78 clinical trials involving 300,000 people that was published in the Cochrane Database found that antioxidant supplements like beta carotene, vitamin A and vitamin E actually increased mortality. A year later, the United States Preventive Services Task Force concluded that there was “limited evidence” that taking vitamins and minerals could prevent cancer and cardiovascular disease.”

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“The task force noted that two clinical trials had found “small, borderline” reductions in cancer incidence in men who took multivitamins. But the group also said there was good evidence that high doses of antioxidants could cause harm.”

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No one could ever be funded to study the untold combinations of a single bottle that contains 30 ingredients. Studies require placing humans at risk long term, not a quick look at test tubes or a few mice.

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The majority who have finances for these products are often among the best fed in the world if not the the most prosperous.

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If you have read this far, you are not the person lumbering to push these truckloads of supplements ahead like Sisyphus.

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Know hope.

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That readers will read.

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Is there any hope with congress?

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Do not overlook the A, B, C’s

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Balancing the harms, the staggering 90% less atrophy has been shown in areas typically harmed by Alzheimers in the OPTIMA study (Oxford Project to Investigate Memory and Ageing) at Oxford University, March 2013, when they looked at persons with mild cognitive impairment (MCI).

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They looked at brain MRI changes in 156 volunteers before and after two years after placebo vs certain doses of B vitamins. No one has tested these doses long term for toxicity. I would never recommend their dose of B6 that has known toxicity to brain and peripheral nerves, see my post here. And they hold a patent on this vitamin regimen, making the protocol potentially suspect.

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It has been shown a few years before, that size of the hippocampus tends to predict Alzheimers to some extent.

 

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We know that those with Major Depressive Disorder and those with chronic low back pain have been shown to develop brain atrophy and memory loss. It would seem essential to test these vitamins again on those groups and replicate the study on mild cognitive impairment, with placebo controlled double blind testing. Again, caution, B6 can be toxic.

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The material on this site is for informational purposes only.
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It is not legal for me to provide medical advice without an examination.

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It is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.

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If you wish an appointment, please telephone the office to schedule.

 

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Health supplements – a brilliant graphic. Are they interfering with YOUR medication?



Some supplements can be extremely helpful for conditions I follow in my practice, while others may harm. Go to this constantly updating link to enlarge a brilliant and very useful bubble graph “like painting with data.”

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Their image is a “balloon race”. The higher a bubble, the greater the evidence for its effectiveness. But the supplements are only effective for the conditions listed inside the bubble.” Try it!

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When you click to the right of their active link to select a medical condition, it will suggest a supplement that has been shown to help. Then return back, below the graphic to check on cautions and toxicity that importantly is not mentioned in their work.

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As explained for the graph, “This visualisation generates itself from this Google Doc. So when new research comes out, we can quickly update the data and regenerate the image.” The Google Doc is a spreadsheet of references from large human, blind, placebo-controlled trials only, sourced from PubMed and Cochrane that publishes leading medical research.

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CAUTION: Toxicity is still important. For example, even though licorice is helpful for coughs, it may seriously increase blood pressure. Valerian may help sleep but may be toxic to liver and may have a withdrawal syndrome.

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Make sure you check here to review the benefits and toxicity to see how supplements may alter your chemotherapy or medication for heart and blood pressure. Another review here: Use of Herbal Products and Potential Interactions in Patients With Cardiovascular Diseases.

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The paper lists several common common drug-herb interactions: Grapefruit juice can be especially risky, increasing your dose of statins and calcium-channel blockers by slowing the metabolism of those prescriptions. St. John’s Wort raises blood pressure and heart rate;  garlic and ginger increase the risk of bleeding in patients on blood thinners. Soy milk and green tea can decrease the effectiveness of warfarin. Ginkgo biloba, ginseng, echinacea, aloe vera and licorice are also discussed.~

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A recent multi-center, double blind, randomized trial of Ginkgo Biloba involving 3,019 subjects over a median of 6.1 years showed that it fails to help memory. Further, a new report in the Journal of Natural Products summarizes beneficial uses but also discusses toxic effects on heart and brain due to the ginkgotoxin. The authors recommend that sales should be restricted. Toxicity to the heart may occur from heart block, ventricular fibrillation and death. And it may lower the seizure threshold in persons with epilepsy. The toxin depletes vitamin B6 in the brain, impairs glutamate metabolism, and triggers seizures via an imbalance in neurotransmitters: high glutamate and low GABA. It has been shown to induce metabolism of epilepsy medication, thus dropping blood serum levels below therapeutic range further increasing risk of seizure.

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Remember to ask your doctor how these may interact with your medication.

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Check here on Vitamin D, a steroid hormone that is anti-inflammatory. Vitamin D is one of the hottest topics in kidney research and hypertension today, as discussed here. And hypertension is important. The latest research on Alzheimers Disease in the last two years from Columbia University Medical School in NYC tells us that risk factors for Alzheimers Disease are the same as for coronary heart disease: exercise, hypertension, cholesterol, obesity, diabetes, smoking. And research suggests that low vitamin D increases risk of cancer of breast, colon, prostate among many other functions. “Vitamin D insufficiency is associated with suboptimal health.

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The material on this site is for informational purposes only, and

is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.

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For My Home Page, click here:  Welcome to my Weblog on Pain Management!

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Vitamin D status and arterial hypertension: a systematic review


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This is an excellent article from Nature Reviews Cardiology, 18 August 2009, and offers doctors CME 0.75 AMA PRA Category 1 Credits. Click blue link below for complete article.

Vitamin D status and arterial hypertension: a systematic review

Stefan Pilz1, Andreas Tomaschitz1, Eberhard Ritz2 & Thomas R. Pieber1

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A short excerpt is included here:

Vitamin D deficiency is common and is primarily caused by a lack of ultraviolet-B (UVB) radiation from reduced sun exposure, and the consequent limiting of vitamin D production in the skin. The vitamin D endocrine system regulates about 3% of the human genome. Observational data support the concept that vitamin D is involved in the pathogenesis of cardiovascular diseases and arterial hypertension. The antihypertensive properties of vitamin D include renoprotective effects, suppression of the renin–angiotensin–aldosterone system, direct effects on vascular cells, and effects on calcium metabolism, including prevention of secondary hyperparathyroidism. The results of clinical studies largely, but not consistently, favor the hypothesis that vitamin D sufficiency promotes lowering of arterial blood pressure. Randomized, placebo-controlled trials are greatly needed to clarify and definitively prove the effect of vitamin D on blood pressure. In general, the antihypertensive effects of vitamin D seem to be particularly prominent in vitamin-D-deficient patients with elevated blood pressure. Thus, in view of the relatively safe and inexpensive way in which vitamin D can be supplemented, we believe that vitamin D supplementation should be prescribed to patients with hypertension and 25-hydroxyvitamin D levels below target values.

Key points
  • Vitamin D deficiency is common and can be attributed to reduced sun exposure, which limits ultraviolet-B (UVB)-induced vitamin D production in the skin
  • Most cells express the vitamin D receptor (VDR) as well as 1alpha-hydroxylase, which underlies several regulatory mechanisms and converts 25-hydroxyvitamin D (25[OH]D; used to classify vitamin D status) to 1,25-dihydroxyvitamin D (1,25[OH]2D)
  • 1,25(OH)2D has high affinity for the VDR, but circulates in lower concentrations than 25(OH)D and is more an indicator of calcium homeostasis and kidney function than vitamin D status
  • About 3% of the human genome is directly or indirectly regulated by the vitamin D endocrine system
  • The antihypertensive effects of vitamin D include renoprotective effects, suppression of the renin–angiotensin–aldosterone system, effects on calcium homeostasis including the prevention of secondary hyperparathyroidism, and vasculoprotection
  • Accumulating evidence—from insights into molecular mechanisms to the outcome of randomized trials—favors the hypothesis that vitamin D deficiency contributes to arterial hypertension, but further data are needed
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Introduction

Vitamin D insufficiency affects almost 50% of the population worldwide.1 This pandemic of hypovitaminosis D can mainly be attributed to lifestyle (for example, reduced outdoor activities) and environmental (for example, air pollution) factors that reduce exposure to sunlight, which is required for ultraviolet-B (UVB)-induced vitamin D production in the skin. Levels of UVB radiation diminish with increasing distance from the earth’s equator, during the winter months, and as a result of air pollution. Black people absorb more UVB in the melanin of their skin than do white people and, therefore, require more sun exposure to produce same amounts of vitamin D.2 Importantly, conditions associated with reduced UVB-induced vitamin D production, such as high latitude, industrialization, and dark skin, have all been associated with increased blood pressure values.2 The logical hypothesis that high UVB-induced vitamin D production is associated with low blood pressure was confirmed by a small trial of 18 patients with untreated essential hypertension.3 The researchers found that systolic and diastolic blood pressure values were reduced by 6 mmHg after 6 weeks of UVB irradiation three times per week. UVB irradiation was also associated with a 162% rise in plasma 25-hydroxyvitamin D (25[OH]D) concentrations, but in hypertensive patients who received UVA irradiation, no significant change in 25(OH)D levels or blood pressure occurred.3

The high prevalence of vitamin D insufficiency is a particularly important public health issue because hypovitaminosis D is an independent risk factor for total mortality in the general population.4 A meta-analysis published in 2007 showed that vitamin D supplementation was associated with significantly reduced mortality.5 Furthermore, vitamin D insufficiency is associated with an increased risk of cardiovascular events, but whether this association reflects a causal relationship remains unclear.6, 7, 8 The effect of vitamin D on blood pressure could be one of the potential mechanisms underlying the link between vitamin D and cardiovascular disease. In this Review, we will summarize the mechanisms that are presumed to underlie the relationship between vitamin D and arterial hypertension, and examine the clinical data for this association.

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Vitamin D metabolism

In humans, the primary source of vitamin D is UVB-induced conversion of 7-dehydrocholesterol to vitamin D in the skin.1 Just 10–20% of our vitamin D comes from dietary sources, such as fish, eggs, or vitamin-D-fortified milk (Figure 1).1 Vitamin D is hydroxylated in the liver to 25(OH)D—the main circulating vitamin D metabolite, which is largely bound to vitamin D binding protein in serum, and is used to classify vitamin D status: vitamin D sufficient (25[OH]D greater than or equal to30 ng/ml [or greater than or equal to75 nmol/l]), vitamin D insufficient (25[OH]D 20–30 ng/ml [or 50–75 nmol/l]), and vitamin D deficient (25[OH]D <20 ng/ml [or <50 nmol/l]).1 These cut-points are currently the most commonly used classification of vitamin D status, but some debate about exact threshold values still exists. Some researchers consider 25(OH)D levels of 10–20 ng/ml (25–50 nmol/l) as vitamin D insufficient and levels below 10 ng/ml (25 nmol/l) as vitamin D deficient, whereas others use a cut-off level of 40 ng/ml (100 nmol/l) to define sufficient vitamin D status.9, 10 25(OH)D is transformed by renal or extrarenal 1alpha-hydroxylase into 1,25-dihydroxyvitamin D (1,25[OH]2D), which circulates at much lower serum concentrations than 25(OH)D, but has a much higher affinity to the vitamin D receptor (VDR).11 Serum levels of 1,25(OH)2D are mainly determined by renal 1,25(OH)2D production, which is closely related to calcium homeostasis, and is upregulated by parathyroid hormone, the concentration of which increases when calcium levels are low.1, 12 In addition, other factors such as fibroblast growth factor 23 and Klotho, which suppress 1alpha-hydroxylase expression, have also been shown to regulate the renal conversion of 25(OH)D to 1,25(OH)2D.13 Studies have, however, shown that many other cell types, including those of the vascular wall, express 1alpha-hydroxylase with subsequent intracellular conversion of 25(OH)D to 1,25(OH)2D, which exerts its effects at the level of the individual cell or tissue before being catabolized to biologically inactive calcitroic acid.1, 12, 14 These intracellular tissue levels of 1,25(OH)2D are determined by the concentration of circulating 25(OH)D, which is, therefore considered the best indicator of whole-body vitamin D status. Importantly, extrarenal 1alpha-hydroxylase expression also underlies various regulatory mechanisms. In this context, extrarenal 1,25(OH)2D production in macrophages is stimulated by Toll-like receptor as part of the innate immune response against intracellular bacteria.15 Another example of extrarenal regulation of 1alpha-hydroxylase is the increased production of 1,25(OH)2D by keratinocytes in wounds, which could be induced by transforming growth factor beta1.16 25(OH)D serum levels, therefore, provide a good estimate of vitamin D status, but regulation of 1alpha-hydroxylase activity should also be considered.

1,25(OH)2D binds to the VDR and, after forming a heterodimer with the retinoid X receptor (RXR), binds to specific DNA sequences—the so called ‘vitamin D responsive elements’. These sequences are located in the promoter regions of various vitamin-D-dependent genes that are either upregulated or downregulated by the RXR–VDR complex.1, 12, 14 Approximately 3% of the human genome is directly or indirectly regulated by the vitamin D endocrine system, which supports the idea that vitamin D insufficiency has widespread adverse consequences for human health.14 In addition to cardiovascular pathology, vitamin D insufficiency can cause musculoskeletal, malignant, metabolic, or immunological diseases.1, 12, 14

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Vitamin D Anti-hypertensive effects

(click link for slide)

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Vitamin D toxicity

When discussing the beneficial effects of vitamin D on blood pressure, one must consider that pharmacological doses of vitamin D have been shown to cause arterial hypertension, vascular stiffness, and atherosclerosis in rodents; whether this finding has any relevance for humans is unclear.129 In humans, vitamin D toxicity and associated hypercalcemia—which can cause reversible hypertension—is observed when 25(OH)D levels are higher than 150 ng/ml (374.4 nmol/l).1 In clinical trials, vitamin D toxicity was not observed with doses of up to 10,000 IU vitamin D per day, which is approximately the level of vitamin D production that can be achieved by endogenous UVB-induced vitamin D synthesis in the skin.130, 131 Consequently, at 10,000 IU vitamin D per day, and in the absence of increased vitamin D sensitivity (for example, sarcoidosis or tuberculosis), vitamin D supplementation is safe. Presumably there is a wide margin between the level of 25(OH)D needed for vitamin D sufficiency (greater than or equal to30 ng/ml [or 75 nmol/l]) and the level of toxicity (>150 ng/ml [or >374.4 nmol/l]).

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Vitamin D supplementation

An intake of 1,000 IU (25 microg) of vitamin D per day can be generally assumed to result in an increase in 25(OH)D levels of approximately 10 ng/ml (25 nmol/l).132, 133 Evidence indicates that daily, weekly, and monthly vitamin D dosing frequencies can equally increase serum 25(OH)D levels, which have a half-life of about 1 month. In this context, an oral vitamin D intake of 1,500 IU daily, 10,500 IU once weekly, or 45,000 IU once every 28 days has been demonstrated to result in similar increases of 15–16 ng/ml (37.4–40.0 nmol/l) in 25(OH)D levels.134 The dose to correct vitamin D deficiency should be sufficiently high to achieve 25(OH)D levels of at least 30 ng/ml (75 nmol/l). For example, a patient with 25(OH)D levels of 10 ng/ml (25 nmol/l) should receive at least 2,000 IU daily, which corresponds to weekly doses of at least 14,000 IU or monthly doses of at least 56,000 IU. Several authors recommend loading doses in the initial phase of treatment (that is, 50,000 IU weekly for 8 weeks or 50,000 IU daily for 1 week) before starting maintenance therapy (that is, at least 1,000 IU vitamin D for a person with initial 25[OH]D levels of 20 ng/ml [50 nmol/l]).1, 10 Individual response to vitamin D doses does, however, vary widely and certain patients, such as those who are obese or suffer from malabsorption, might require much higher vitamin D doses than individuals without comorbidities.1, 133 Measurements of 25(OH)D levels are, therefore, useful to monitor 25(OH)D levels and to allow for adequate correction of the vitamin D dose. 25(OH)D levels should be reassessed 3–6 months after initiation of vitamin D supplementation. In patients with increased vitamin D sensitivity, such as those with sarcoidosis or tuberculosis, calcium should be measured in the initial phase of treatment. One problem with vitamin D treatment is that, although maintaining 25(OH)D levels above 30 ng/ml (75 nmol/l) is generally recommended, no consensus exists about optimal 25(OH)D levels. At present, many researchers recommend maintaining 25(OH)D levels between 30 and 60 ng/ml (75.0–149.8 nmol/l).1, 10 We do not know whether higher levels than this are beneficial or detrimental. Data from NHANES-III indicate a ‘J-shaped’ association between 25(OH)D levels and mortality, with the highest mortality in persons with the lowest 25(OH)D levels, but with slightly increasing mortality in those with supraphysiological 25(OH)D levels. However, other data indicate that particularly high levels of vitamin D are optimal for cancer prevention.4, 10

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Conclusions

Accumulating evidence, ranging from insights into molecular mechanisms to the outcome of randomized controlled trials, favors the hypothesis that vitamin D deficiency contributes to arterial hypertension. The antihypertensive effects of vitamin D are mediated by renoprotective effects, suppression of the RAAS, by beneficial effects on calcium homeostasis, including the prevention of secondary hyperparathyroidism, and by vasculoprotection. However, definitive evidence from appropriately powered, controlled, intervention trials is lacking. Some inconsistent results from studies of the relationship between vitamin D status and arterial hypertension have been reported, possibly because the effects of 25(OH)D on blood pressure are not apparent in normotensive individuals with 25(OH)D levels within the normal range. In general, evidence for the antihypertensive effects of vitamin D is strongest in patients with elevated blood pressure and vitamin D deficiency; these patients would, in our opinion, benefit from vitamin D supplementation. In addition to cardiovascular sequelae, vitamin D deficiency has been associated with autoimmune, malignant, neurological, metabolic, and infectious diseases, as well as with bone fractures.1, 12, 14, 117, 130, 131 In view of the multiple health benefits of vitamin D and the high prevalence of vitamin D deficiency, as well as the easy, safe, and inexpensive ways in which vitamin D can be supplemented, we believe that the implementation of public health strategies for maintaining a sufficient vitamin D status of the general population is warranted.1, 12, 117, 130, 131

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Medical Library


This page at the National Library of Medicine or Medical Librarymay be useful to you, allowing you to search for the explanation of Medical Conditions, Medications, Procedures, Tests, and general questions.

Other active links – click to open

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Other  organizations include American College of Emergency Physicians, National Hospice and Palliative Care Organization, Family Caregiver Alliance, American Bar Association Commission on Law & Aging.

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Communicate promptly with your provider with any health related questions or concerns.

 

Vitamins and Herbs – Risks and Benefits


Most doctors have little if any training in vitamins and supplements

except as they relate to their specialty.

My field of neurology concerns itself with metabolic and nutritional diseases more than most areas of expertise, and I have an interest in several vitamins because of research related to major causes of mortality in the United States.

During the period I taught at a cancer center, I was concerned that research protocols may be misleading as these supplements were not accounted for, however since that time in the mid 90’s, I’m glad that public interest has pushed this field into the fore.  Major cancer centers now have active research in Complementary and Integrative Medicine (CAM) because there are risks and benefits, and some have significant herb-drug interactions as discussed below.

Check your vitamins and supplements for toxicity

Because of the growing science on toxicity, usefulness, and drug interactions, if you use vitamins, review each one carefully with your physician and with the websites listed in the column on your right. Some “vitamins” are simply brand names that have over 20 different vitamins, minerals and various ingredients.  This means you must review each one for current research benefits and risks.

At special risk for vitamin deficiencies are those who have highly restricted diets, abdominal resection, intestinal conditions, colitis, Celiac Disease, gastric bypass, HIV, or the elderly.

Pregnant women have special needs that are essential not only for their own health but to reduce the risk of neurological defects in the fetus.  It is essential in their case to work closely with their obstetrician, especially if morning sickness prevents them from taking their daily supplement.

Resources

One of the best resources I have found is Memorial Sloan Kettering Cancer Center’s Herbs and Botanicals, also linked on the column at right.  Their website is updated frequently with an excellent review of the literature.  It is hosted by a senior physician who has specialized in the field for decades and is actively involved in research at their center as well as NIH.

MD Anderson Cancer Center’s Complementary/Integrative Medicine Education Resources website andColumbia University’s Rosenthal Center for Complementary and Alternative Medicine are two others, but there are other resources on the web and books that are excellent.

Recipe for Rum Soaked Salmon with Apple Ginger Puree is found here.

VITAMINS & SUPPLEMENTS

Vitamin D has become a major research topic in recent years.  It may play a more important role than any listed below.   I have written separately on it and its controversy in greater detail.  Please refer to the last post by scrolling down.

Fish Oil

Omega 3 Fish Oils are polyunsaturated fatty acids that are essential for health yet cannot be made by the body.  Unless you eat several servings per week of fatty fish or wild salmon, not farmed salmon, it is one of the most important supplements that any adult of any age can take.  They are needed for building cell membranes in the brain but our body does not make them.   Fish oil helps your lipid profile by reducing triglycerides as much as 45%.  It reduces platelet clotting, lowers risk of heart attack and cardiac arrhythmia, and is an important anti-inflammatory reducing pain for many particularly those with arthritis.  One of thebest references on Omega 3 Fatty Acids is by  Dr. Frank Sacks, Professor of Cardiovascular Disease Prevention, Department of Nutrition, Harvard School of Public Health.   He mentions high doses “are used to treat depression. New studies are identifying potential benefits for a wide range of conditions including cancer, inflammatory bowel disease, and other autoimmune diseases such as lupus and rheumatoid arthritis.”

One high quality fish oil, Lovaza, has been approved by the FDA and is prescription only.  Fish oil and cod liver oil available over the counter should be checked for adequate dosages of EPA and DHA that will vary with your needs as determined by your lipid profile, and should be purified to remove cholesterol, dioxin, PCB’s and other pesticides.

Co-Enzyme Q10 is also called CoQ10.  CoQ10 is present in every cell of the body which is why it is also called ubiquinone.  It is important in the electron transport chain to produce intracellular energy.

Statins deplete CoQ10. Vitaline’s CoQ10 product has been used in NIH funded trials for cardiovascular, neurological and brain disorders. Two mitochondrial disorders have been shown to benefit from Co-Q10: migraine and Parkinsons Disease.

My preferred manufacturer is Vitaline because of their research with NIH which requires that they validate and verify dosages.  Their website discusses other advantages and gives guidance on dosages that have shown benefit for various conditions. They offer a discount of 25% if you request scheduled delivery every 3 months.  Use the code code DEF25.  Their product is in the form of wafers that are about the size of a quarter and are very easy to break into 2 or 4 with your hands.

Vitamin B supplements in the elderly may help reduce the risk of dementia and B12 deficiency may result in neurological conditions such as peripheral neuropathy, dementia, hematologic and psychiatric disorders, Subacute Combined Degeneration of spinal cord & brain, increased fracture risk, and may increase the risk of cardiovascular diseases.  A good B complex vitamin is not likely to harm and may benefit.    The best source of all is food:  leafy green vegetables, beans and peas.

Thiamine (Vitamin B1) in high doses of 300 mg per day may reduce kidney disease in type 2 diabetes and may prevent early diabetic cardiomyopathy (heart disease).  As many as 70% to 90% of people with diabetes, both type 1 and type 2, are thiamine deficient.  The research is still a little early to draw firm conclusions.  It is being done by Charity Diabetes UK which finds that thiamine works by helping protect cells against the harmful effects of the high blood sugar levels.”

Vitamin A is associated with a 45% risk of hip fracture.  There are four major adverse effects of high levels: birth defects, liver abnormalities, reduced bone mineral density that may result in osteoporosis, and central nervous system disorders.

Vitamin E may actually increase mortality and there are significant risks to its use including increased risk of some cancers.  Several studies were reviewed by one of the foremost science writers, Jane Brody, in the New York Times on March 23, 2009.  It does not reduce the risk of cardiovascular disease, stroke, dementia, mild cognitive impairment, and there is no evidence that it slows the progression of macular degeneration.  In thePhysicians’ Health Study II it has been shown to actually increase the risk of hemorrhagic stroke since it decreases the clotting tendency of blood.

Vitamin C was recently shown to markedly increase the growth of cancers. It’s healthy for them too.  It blunts the effect of cancer drugs by as much as 30 to 70% depending upon the drug tested.

Zinc may prevent the absorption of copper which is necessary for the brain and spinal cord thus resulting in progressive neurological conditions.  Herb-drug interaction reduces the bioavailability of some antibiotics, tetracycline and fluoroquinolones.  Intake of 100-300 mg/day may result in chronic toxicity including copper deficiency, depressed immune function, headache, chills, fever, and fatigue.  It concentrates in the prostate and consumption of more than 100 mg per day may increase risk of prostate cancer.

It may be useful for tinnitus and for short term use to reduce symptoms of the common cold when used topically or in lozenges

HERBS & BOTANICALS

Don’t forget seeds, beans and whole grains that help digestion and keep the system moving!

This is a very brief summary of a few of the more commonly used herbs.  Please refer to Memorial Sloan Kettering Herbs and Botanicals website for detailed information on risks and benefits.

Arnica – a topical anti-inflammatory may help sprains and osteoarthritis.

Aloe Vera – apply immediately after sunburn or burning the skin to prevent blister formation

Chamomile – calming sedative, may use for intestinal colic or gas

Cat’s Claw – anti-inflammatory activity may be caused by the inhibition of TNF-alpha production.  It may be useful for refractory oral ulcers of unknown etiology in persons with HIV/AIDS that have not responded to other known remedies.

Echinacea may shorten the duration of common cold, useful in sinusitis, and respiratory infections.  Because of the lack of standardization of various products, I recommend a high quality organic liquid product by HerbPharm. Avoid use in autoimmune conditions, Multiple Sclerosis, HIV/AIDS.  “Echinacea was shown to stimulate phagocytosis, enhance mobility of leukocytes, stimulate TNF and interleukin 1 secretion from macrophages and lymphocytes, and improve respiratory activity… both in vitro and in vivo.”

Goldenseal is anti-inflammatory, antimicrobial with activity against pathogens such enterotoxigenic E. coli and V. cholera that may be useful for bacterial sinusitis and respiratory infections.   Warning it may prolong the QTc interval in persons with heart disease or those on methadone and it is contraindicated in persons with hypertension.  A high quality organic liquid product is made by HerbPharm.

Medicinal Marijuana is a vast subject. I would be happy to schedule time to discuss its medical use with you. Refer here for some of the known research and patient information.

Red Yeast Rice, a naturally occurring statin, the same as Lovastatin, often used in China.   Make sure your doctor knows this and monitors liver function.  Statins may cause severe muscle and joint pain that may potentially lead to rhabdomyolysis (sudden death of muscles), kidney failure, vasculitis, lupus-like syndrome, and many other symptoms, however most people tolerate them without side effects and they have dramatically reduced the incidence of heart attacks and stroke.  They may also reduce the risk of dementia including Alzheimer’s type dementia.

Turmuric (Curcumin) – may alleviate irritable bowel syndrome and ulcerative colitis.  There is a suggestion of improved cognitive performance from epidemiology studies but studies show no benefit for Alzheimer’s Disease.  Avoid use if you have gallstones.  It may inhibit the action of some chemotherapy drugs, such as used for breast cancer, but may be beneficial for certain cancers and other chemotherapy drugs.

Wheat grass– a natural source of vitamins and minerals (Chlorophyll, Vitamins A, C, E, K and B-complex, Iron, Calcium, Magnesium,  Selenium,  Amino acids); may have antioxidant effects.

Willow Bark – contains salicin, the precursor of aspirin.

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The material on this site is for informational purposes only.

It is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.

To Find My Home Page, click here:  

Welcome to my Weblog on Pain Management!

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Vitamin D – A Steroid Hormone, Anti-inflammatory


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The Sunshine Vitamin Controversy

What should normal values  be for calcium homeostasis?

My attention was drawn to Vitamin D several years ago when a review appeared in the journal Neurology, published by the Academy of Neurology, that linked low levels of Vitamin D to Multiple Sclerosis.  The article was unusual for its length and the breadth of research cited over several decades.  More recently, a Johns Hopkins article published “the most conclusive evidence to date” that Low Vitamin D Levels Pose Large Threat to Health.

New publications on Vitamin D seem to appear every week with the focus on levels of 25-hydroxyvitamin D, also written as 25(OH)D. Its half life in serum is ~ 10 days to 3 weeks.

The biologically active form 1,25-dihydroxyvitamin D, written as 1,25(OH)D²,  is made in the kidneys and has a much shorter serum half-life of ~ 4-6 hours, thus making it less useful as a serum marker for measuring.

Sources & Metabolism: Vitamin D is a fat soluble vitamin that’s absorbed in the small intestine from  foods such as egg yolks, fatty fish, fish liver oils, fortified milk, margarine, and cereals.  Bile salts are required for absorption.  Sunlight stimulates the skin to synthesize vitamin D, but exposure of hands and face as little as 15 minutes may not be sufficient and it is not as effective for everyone.  It won’t work in winter months, it won’t work for the aged, for those who have pigmented skin, and it won’t work for those who cover their skin.

Vitamin D Metabolism - click to enlarge

Vitamin D Metabolism

The Controversy –  How Do We Determine Normal Values?

Surprisingly, in a well designed multicenter study of healthy young Hawaiians in their 20’s who were exposed to at least 29 hours of sun per week, 51% were found to have vitamin D deficiency using the usual cut off of 30 ng/ml for normal.  This study from 2007 found the mean concentration of 31.6 ng/ml, and the highest of 62 ng/ml.  It raises the question whether

“it seems prudent to use this value [60 ng/ml] as an upper limit when prescribing vitamin D supplementation,”

rather than the generally published normal range of 30 to 80 ng/ml or even 100 ng/ml quoted in some labs.  This study is important in discussing the controversial question of what normal values should be for calcium homeostasis and reviews several possible explanations for inadequate production of D3 including genetic differences.

They note the highest reported values in “Nebraska outdoor workers… were between 81 and 84 ng/ml” but the assay system differed compared to theirs and results in a higher value.   Reviewing this study that was published in the Journal of Clinical Endocrinology & Metabolism has allowed me just now to readjust my own patient practice.

Laboratory Testing:  results can differ from one laboratory to another.  My hospital sends specimens to ARUP for testing, whereas Quest has acknowledged errors in laboratory testing and problems with standardization as reported by the New York Times here.

Function:  It is important for absorption of calcium and phosphorous from the small intestine, for bone health, osteoporosis, risk of falls, certain cancers(colon, breast, prostate), and possibly 6 to 7 years of longevity.  Deficiency of vitamin D is associated with suboptimal health and possibly increased pain; it is linked to infections, gum disease, hypertension, diabetes, coronary disease, neurological diseases such as Multiple Sclerosis, Parkinson’s Disease, dementia and Alzheimer’s Disease though it may not be causal. Its receptor is found all over the body including the brain.

I recommend this review by one of the best web resources at Memorial Sloan Kettering Cancer Center Herbs & Botanicals.

They quote a reference showing it reduces postmenopausal weight gain and “In adults with impaired fasting blood glucose, giving calcium and vitamin D reduced increases in plasma glucose and insulin resistance….”

It is the only vitamin that is a steroid hormone, and my interest increased on learning that it functions as an anti-inflammatory.  But as I tested blood levels for 25(OH) vitamin D and parathyroid hormone (PTH), I discovered more than 90% of my patients had vitamin D deficiency and a few had hyperparathyroidism.  There are four parathyroid glands next to the thyroid, and for some reason doctors have rarely tested their hormone levels.

***Persons with hyperparathyroidism should NOT take calcium or vitamin D.

It may lead to kidney stones and bone pain:  stones, bones and groans.***

Evidence for Optimizing Vitamin D Concentrations

On the other hand, if vitamin D is low, there is some evidence that replacement with vitamin D3 so that blood levels are in the high normal range, may help pain.  That is, it may raise the pain threshold and possibly have other benefits for health and longevity. It is desirable to avoid toxic levels of D as it causes hypercalcemia with depression, drowsiness, weakness, headache, polydipsia,  bone loss, and metastatic calcifications of many organs, soft tissues and blood vessels.  The generally quoted range of normal for 25(OH) vitamin D is 30 to 80, that varies with the lab.

great-western-divide-wp1

Doesn’t that photo of the Great Western Divide make you want to get outside into the sun?

Estimation of optimal serum concentrations of 25-hydroxyvitamin D for multiple health outcomes was reviewed by Heike Bischoff-Ferrari et al, in 2006,  though it has been superseded by much additional work since then.

To quote from their article:

This review summarizes the evidence for optimal serum  25(OH)D concentrations. The endpoint selection for this review was based the strongest evidence to date—ie, that from RCTs [randomized controlled trials], consistent evidence from prospective and cross-sectional epidemiologic studies, and strong mechanistic evidence or dose response relations.  BMD [bone mineral density], fracture prevention, lower-extremity function, falls, oral health, and colorectal cancer met these criteria. Weaker evidence exists of a beneficial effect of vitamin D on other diseases, including multiple sclerosis (15), tuberculosis (16), insulin resistance (17, 18), cancers other than colorectal (19 –22), osteoarthritis (23, 24), and hypertension (25–27), but these diseases are not considered here.

They did not review pain studies.  I would add that “weaker” evidence merely means that it must be confirmed by more studies, not that it excludes those conditions.  There is an epidemic of vitamin D deficiency in the country, and the incidence is very high in pain clinics as reported in several studies.

A new multi-center epidemiology study  “Demographic Differences and Trends of Vitamin D Insufficiency in the US Population, 1988-2004”  by Ginde, et al, in 2006,  “demonstrate a marked decrease in serum 25(OH)D levels from the 1988-1994 to the 2001-2004 NHANES data collections.”  And like others before them, they point out:

“Current recommendations for vitamin D supplementation are inadequate to address the growing epidemic of vitamin D insufficiency.”

Summary:

Make sure your doctor checks both your 25(OH)Vitamin D and parathyroid hormone level (PTH) – not thyroid – to determine if you have hyperparathyroidism or if you have normal or low vitamin D.  That will determine if you need replacement or if you should stop using calcium and D as it will cause kidney stones and calcium deposits on your bones leading to pain.

If vitamin D levels are low it may result in increased physical pain and may cause or aggravate many medical conditions.

If PTH levels are high indicating hyperparathyroidism it will cause new painful conditions.

Intake does vary with the patient, the season, the age, but the recommended daily allowance may perhaps be double what it is now.  It is unclear when the federal government will adjust that dosage.   As always, your physician’s recommendation will be based upon blood levels of 25(OH)D and PTH.

Do not make changes in your dosage without careful evaluation.

Could this possibly be one of the most important areas of research this century?

The material on this site is for informational purposes only, and

is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.

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