1 / 36

Vitamin Update

Vitamin Update. Frank J. Domino, M.D. Associate Professor Family Medicine Clerkship Director Dept. of Family Medicine & Community Health Un. Of Massachusetts Medical School. Disclosure. Editor in Chief: 5 Minute Clinical Consult Author and Editor for Up To Date

harvey
Download Presentation

Vitamin Update

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Vitamin Update Frank J. Domino, M.D. Associate Professor Family Medicine Clerkship Director Dept. of Family Medicine & Community Health Un. Of Massachusetts Medical School

  2. Disclosure • Editor in Chief: 5 Minute Clinical Consult • Author and Editor for Up To Date • Pri Med Curriculum Committee • Author/Editor: • www.Epocrates.com, Rxpalm, Inc., • www.Familydoctor.org

  3. Objectives • Review most current data on the role of vitamins for the prevention of illness • Describe and interpret some of the recent literature base on a variety of agents commonly used and why they have become so popular • Review and summarize what does provide disease prevention and benefit.

  4. What we spend…. • 2007 CDC: 34 Billion on Alternative Care • 15 Billion on Vitamins & Supplements • 12 Billion on acupuncturists, chiropractors, massage therapists • 3 Billion on Homeopathy • Motivating Reasons: Pain and Fear

  5. Vitamins -Mediterranean diets: fruits and vegetables, Olive Oil and some nuts correlate with lower rates of heart disease and cancer -Packing all of that good stuff into a daily supplement should result in a similar benefit? -What works and what doesn’t

  6. Antioxidant substances include Beta-carotene Lutein Lycopene Selenium Vitamin A Vitamin C Vitamin E

  7. Anti Oxidants Vitamin C (500 mg) Vitamin E (600 IU QOD) Beta Carotene (50mg QOD) In combinations (2x2x2) 8000+ Women x 9.4 years No benefit Cancer Mortality No Benefit in Overall Mortality J Natl Can Inst 2009; 101: 14-23

  8. Vitamin C and E Prostate Cancer Physician’s Health Study II, 14,000+ Men RCT 2x2 Factorial Study: Vit. E 400 IU + Vit. C 500 mg/day x 8 Yrs No Decrease in Prostate Cancer or Total Cancer JAMA 2009; 301(1): 52-62

  9. Selenium and Vitamin E 35,000+ Men US, Canada, Puerto Rico 2x2 Factorial Study Selenium 200 ug/d, Vit. E IU/d x 5.4 Yr No Significant Decrease in any cancer Slight Non-Sig. INCREASE in Prostate Cancer in Vitamin E Type 2 DM in Selenium + Vit. E JAMA 2009; 301(1): 39-51

  10. Anti-oxidants: CDSR Vitamin A, C, E, Selenium, beta-carotene, Selenium CDSR: 230,000 Patients from 68 studies No significant reduction in overall mortality Restricted to 47 high quality RCT, -> INCREASE in mortality (RR 1.05, 95% CI 1.02-1.08) Cochrane DBSR: 2008; 16(2)

  11. Folic Acid, B6 & B12 on Cancer Risk in Women 5400 female health professionals >/= 42 Yr with: Known CAD or 3 or more CHD Risk Factors x 7.3 years Folic Acid 2.5 mg Vit. B6 50 mg+Vit B12 1 mg/day No effect on breast cancer or Total Cancer Risk JAMA 2008; 300(17): 2012-2021

  12. Multi Vitamins: WHI 161,000+ Women (68K RCT, 93K Cohort) x 8 Years MVI Use and Cancer, CHD, Mortality No Association between MVI and Decrease in: - Any cancer risk (Breast, C/Rectal, Endometrial, Lung, Ovarian), CVD, MI, Stroke, DVT or Mortality Arch Intern Med. 2009;169(3):294-304

  13. Famous Correlations that were not Cause & Effect Blood Letting and Health Antibiotics for Otitis Media Binding Free Radicals and Cancer Vitamin C and improved immunity Low Fat foods and Wt. Loss College Education and Job Security “No Down Payment” Mortgage & Home Ownership

  14. CHD & Folic Acid ↑ homocysteine associated with ↑ risk of cardiovascular disease. Supplementation with folic acid, vitamin B6, and vitamin B12 can lower homocysteine levels THEREFORE: ↓ Homocysteine should lower CHD risk, right?

  15. Folic Acid and CHD SR of 12 RCT of folic acid vs placebo in >16,000 patients w/CHD NO: decrease in CVD, CHD, CVA & All-Cause Mortality JAMA: 2006; 296(22): 2720 Meta-analysis of 5 RCT for 2nd Prevention of CVD in 10,000+ patients No Significant Outcome improvement BUT slight, non-significant trend to increased CHD risk in Folic Acid group Lancet: 2005; 366(9518):1679

  16. Ginko biloba for Prevention of Dementia RCT: >/= 75; 2500 Nl + 482 Mild Cog. Impairment Ginko 120 mg bid vs. placebo x 8 years No Sig risk reduction in Ginko group No effect on progression to Dementia in MCI group JAMA 2008; 300(19): 2253

  17. USPSTF AGAINST: Beta Carotene Insufficient to recommend for/against: --Vitamin A, C, E --Multivitamins w/folic acid or anti oxidant for prevention of CHD or Cancer Ann. Int Med 2003; 139(1):56

  18. So, what Vitamins WORK?

  19. Vitamin D Little new DIRECT outcome data 1. Vit D. Deficiency  ↑ Risk: Cardiovascular Disease Death from MI/CHD Arch Intern Med 2008; 168(11): 1174 First Cardiac Event Circulation 2008; 117(4): 503 2. Vitamin D Supp  ↓ Risk of Falls in Seniors (700-1000/d) Bischoff-Ferrari; : BMJ. 2009 Oct 1;339:b3692 AND  ↓Rates of Nonvertebral Fractures; (Hip) RR = 0.82 Arch Inter Med 2009; 169(6): 551 3. HTN: Short term data (8-12 weeks) Average ↓: Systolic >5 mmHg (NNT=3), Diastolic >5 mmHg (NNT=7) J Clin Endo Met 2001; 86(4): 1633

  20. Early Data on Vitamin D Supplementation ↓URI w/2000 IU/d Epid Infect 2009; (10):1396-404 ↑ Athletic Performance Med Sci Sports 2008; 41(5): 1102 ↓Risk of Breast and Colon Ca Am J Public Health. 2006 Feb;96(2):252-61 Prenatal Replacement  ↓ Pediatric Asthma Slow (& ? Prevent) Osteoarthritis Prevent Multiple Sclerosis (Neuro 2004; 62: 60) Recommend: Breastfed 400 IU at 2 months Children 1000 IU/Day Adults 2000 IU/Day

  21. More on Vitamin D, Obesity and Diabetes • Calcium+D during weight-loss enhances weight loss & lipoprotein profile in T2DM • Am J Clin Nutr. 2007 Jan;85(1):54-9. • But Calcium alone did not improve outcomes • Ann Intern Med. 2009 Jun 16;150(12):821-9, W145-6 • Vitamin D reduces insulin resistance in S. Asian women of New Zealand with Vitamin D Deficiency • Br J Nutr. 2010 Feb;103(4):549-55. • Treating VDD in T2DM improves insulin secretion • Int J Clin Pract. 2003 May;57(4):258-61. • VDD associated w/ SubQ & Visceral adiposity • Diabetes. 2010 Jan;59(1):242-8

  22. Vit D Def = ↑ Risk of Death Melamed: Cohort 13,000 NHANES Lowest quartile ↑ Risk of All Cause Mortality RR=1.26 (95% CI 1.08 - 1.46) Arch Intern Med. 2008;168:1629-1637. Cohort Study of 3,200+ consecutive adults scheduled for Coronary Angiography at 1 SW Germany Hospital x ~ 8 Years 22.6% died; Most with CHD 2 lowest 25 Vit D levels -> HR 2.08 (CHD HR =2.22) Dobnig 2008; Arch Int Med 168(12): 1340

  23. What Prevents All Cause Mortality? • Seatbelts • Clean Water • Vaccines

  24. Prevention of All Cause Mortality Meta Analysis:18 studies of 57,000+ Adults Examined Risk of Death Any Cause in RCT Vitamin D Supplementation Average dose > 500 IU/D Decrease in All Cause Mortality (RR = 0.93) Autier: Arch Int Med 2007;167(16): 1730

  25. Institute of Medicine 980 Pages…

  26. Vitamin D • Vitamin D’s job is to regulate serum Ca • Annual High Dose Vitamin D & Fractures • RCT of 500,000 IU D3 x 3-5 Years • ↑ Risk of Falls (83/100 Per Yrs vs 72/100 PY) • ↑ Risk of Fx (4.9/100 PY vs 3.9/100 PY) JAMA 2010; 303(18): 1815-22; Editorial 1861

  27. Fish OilDHA: docosahexaenonic AcidEPA eicosapentaenoic Acid Cardiac: Meta-Analysis of CHD Pts: Reduces Cardiac Death but no effect on arrhythmia or All Cause Mortality BMJ 2009: 338: a2931 Infection: 180 Thai children (9-12) 200 mg EPA + 1 gm. DHA 5 d/wk vs placebo few & shorter “infections” vs placebo J Pedia 2008; 154(3): 391-395

  28. Vitamin C • Vitamin C DOES prevents Scurvy • Disease of impaired collagen synthesis • Symptoms: ecchymoses, bleeding, petechiae, hyperkeratosis, Sjogren's syndrome, arthralgias, impaired wound healing BUT • Vitamin C to lower LDL—Not • Circulation 1999 Feb 2;99(4):591-5 • Prevent or Tx URI—Not • Cochrane Database Syst Rev. 2007 Jul 18;(3) • Can cause False + guaiac stools • May increase risk of calcium oxalate stones

  29. Vitamin C is finally good for more than Scurvy… Cohort trial of ~47,000 Men Surveyed Vitamin C & new onset Gout 20 Years Follow up Compared to < 250 mg/d 500-999 mg/d  RR= 0.83 1000-1499 mg/d  RR= 0.66 >/= 1500 mg/d  RR = 0.55 Arch Intern Med 2009 169(5): 502 p<0.001 45

  30. Elderberry Extract for Influenza • 3 Small Randomized Controlled trials • Elderberry Extract Lozenges (175 mg) vs placebo QID for 2 days • 20% reduction in fever & flu symptoms • No Adverse Events • J Pharmacol Pharmacokin; 2009: 5:23 • Duration of illness shorter by 29 h (25% reduction vs placebo) • COMPARED TO: Tamiflu (oseltamivir) • Duration of illness shorter by 16.8 hours vs placebo • Elderberry not proven to PREVENT Influenza

  31. Pelargonium sidoides extract for Acute Bronchitis • Cochrane Systematic review in 6 trials of adults and children • Complete resolution at day 7 • Liquid: 39% vs 5%, NNT = 3 • Tablet: 7% vs 1%, NNT = 15 • CDSR 2008; 16(3) • NOT recommended in pregnant or breastfeeding women or children < 6 years

  32. Zinc • 15 trials, 1300 Participants • Zinc lozenges (or syrup), started within 24 hours of symptoms, reduced the severity and duration of cold symptoms. • Risk of symptoms at day 7 was 50% less than without Zinc • Prevention: taking zinc supplements for 5 months reduces: • Cold Incidence • School Absenteeism • Antibiotic Rx for Children CDSR 2011; Meenu, Issue 2

  33. Yogurt Drink to prevent Abx Associated Diarrhea • 135 In Patients on High Risk IV Abx • Lactobacillus casei, L bulgaricus, and Streptococcus thermophilus • Twice a day during a course of antibiotics and for one week after the course finished • Diarrhea: 12% Int. vs 34% Placebo • ? C. difficile • NNT = 5 BMJ. 2007 Jul 14;335(7610):80

  34. Summary What Does NOT Work: • Anti Oxidants & Multi Vitamins • Folic Acid supplementation on CHD risk • GinkoBiloba and prevent Dementia • Vitamin C risk of infection or treat URI What Does WORK: • Vitamin C DOES LOWER risk of gout in men • Vitamin D DOES LOWER all cause mortality, and will decrease risk of falls in seniors, decrease of CHD and Cancer, and may prevent osteoporosis • Omega 3 Fatty Acids DOES lower risk of CHD Death • Consider Elderberry Extract for Influenza symptoms • Consider Pelargonium sidoides syrup for Bronchitis • Zinc treats & Prevents URI’s • Yogurt Drink may help prevent Abx Diarrhea

  35. Get Vitamins the Old Fashioned Way Frank.domino@umassmemorial.org

More Related