The following excerpt from the Vitamin D Council’s newsletter is interesting and well documented, so we have chosen to reprint it.
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Last month Dr. Armin Zittermann of Ruhr University, Germany, published the best vitamin D paper of the month. He reviewed the mounting evidence that vitamin D deficiency is a major cause of heart disease.
Br J Nutr. 2005 Oct;94(4):483-92.
Before we start, let's talk about paradigms and paradoxes. A paradigm is a set of assumptions, concepts, and practices that constitutes a way of viewing reality. The current paradigm is that heart disease is caused by a combination of genetics, hypertension, diabetes, cholesterol, smoking, obesity, inactivity, and diet. A paradox is a fact that contradicts the paradigm.
The Framingham Risk Equation is an attempt to use the most reliable risk factors in a paradigm to predict who will get heart disease. When researchers applied it to British men for ten years, they found 84% of the heart disease occurred in the men classified as low risk! Furthermore, 75% of the men classified as high risk were still free of heart disease by the end of the tenth year! It appears the equation may be missing a few variables.
BMJ. 2003 Nov 29;327(7426):1267.
This month's Vitamin D Quiz reveals several interesting heart disease paradoxes-and some of them just might surprise you. Positive you know what causes heart disease? Let's find out...
1. The French Paradox is that cardiovascular disease is relatively low in France, despite high intakes of saturated fats.
A. True
B. False
True. Perhaps the best known of the cardiovascular disease paradoxes, it was first described in 1987, before the dermatologists scared the French out of their bikinis. The most common explanation is that the French love red wine, known for the antioxidants it contains. But the rates of cardiovascular mortality in France are much lower in the South and the West than they are in the North. One of the world's best vitamin D researchers, Dr. Marie Chapuy, found that vitamin D levels of healthy adults in France follow that same pattern, with a mean level of 38 ng/mL in the sunnier and drier South and West, but less than half that (17 ng/mL) in the colder, rainier, more polluted North.
Arch Mal Coeur Vaiss. 1987 Apr;80 Spec No:17-21.
Hypertension. 2005 Oct;46(4):645-6. Epub 2005 Sep 12.
Hypertension. 2005 Oct;46(4):645-6. Epub 2005 Sep 12.
Osteoporos Int. 1997;7(5):439-43.
2. The Israeli Paradox is that cardiovascular disease is high in Israel, despite a high consumption of polyunsaturated omega-6 fats.
A. True
B. False
True. Now, according to the current paradigm, polyunsaturated fats contained in vegetable seed oils are supposed to lower the risk of heart disease. Yet, high consumption of these oils doesn't seem to have prevented the Israelis from dying from heart attacks. However, despite its sunny weather, Israel does have a high incidence of vitamin D deficiency. Average vitamin D levels among healthy adults in Lebanon, right next door, are only 9.7 ng/mL-dangerously low. Healthy Jewish mothers, especially orthodox ones, have low vitamin D levels. (If you are wondering how the pro-inflammatory omega-6 oils could ever help heart disease, one possibility is these oils dissociate vitamin D from its binding protein, making more free vitamin D available. Apparently, the Israelis don't have enough vitamin D in their blood to dissociate).
Isr J Med Sci. 1996 Nov;32(11):1134-43.
Isr Med Assoc J. 2004 Feb;6(2):82-7.
J Bone Miner Res. 2000 Sep;15(9):1856-62.
Isr Med Assoc J. 2001 Jun;3(6):419-21.
J Steroid Biochem Mol Biol. 1992 Sep;42(8):855-61.
3. The Italian Paradox is that a population of heavy smokers has a low incidence of cardiovascular disease.
A. True
B. False
True. The overall death rate from cardiovascular disease in Italy, a country of heavy smokers, is relatively low. Before you say it is the olive oil and wine, ask yourself where do those olive trees and grapevines grow?-In the sun, of course! However, at least two good studies show vitamin D levels in Europe are a paradox, the closer a European lives to the equator, the lower their vitamin D level. Nevertheless, an Italian study showed healthy Roman blood donors had robust vitamin D levels of 48 ng/mL in the summer. Even average postmenopausal Italian women reached 36 ng/mL in the summer. Anyone who has traveled in Italy knows that most Italians love the sun. As the old Italian proverb points out: "Where the sun does not go, the doctor does."
QJM. 2000 Jun;93(6):375-83.
Br J Nutr. 1999 Feb;81(2):133-7.
4. The Northern Ireland Paradox is a very high incidence of coronary heart disease, yet very few of the expected risk factors.
A. True
B. False
True. In fact, the age adjusted mortality for coronary artery disease was more than four times higher in Belfast than in Toulouse, France, despite almost identical coronary risk factors. There were 761 deaths per 100,000 in Belfast compared to 175 in Toulouse. This is hard to explain, given the current paradigm of heart disease. Of interest, Belfast is at 54 degrees latitude, at sea level, and has 257 rainy days per year. Toulouse is eleven degrees closer to the equator with an altitude that is 500 feet closer to the sun and only 74 rainy days per year. Lots more vitamin D in Toulouse!
QJM. 1995 Jul;88(7):469-77.
QJM. 1998 Oct;91(10):667-76.
Weatherbase, Belfast.
Weatherbase, Toulouse.
5. The Indian Paradox is a high prevalence of coronary artery disease in urban Indians despite their low saturated fat intake.
A. True
B. False
True. Researchers found that a diet low in saturated fats did not prevent heart disease in the citizens of the brass-works-polluted city of Moradabad in northern India. The authors did not mention that air pollution dramatically lowers vitamin D levels.
J Am Coll Nutr. 1998 Aug;17(4):342-50.
Arch Dis Child. 2002 Aug;87(2):111-3.
6. The Swedish Paradox is that the association between cold weather and heart disease in Sweden is not explained by the usual risk factors.
A. True
B. False
True. Researchers tried to explain why higher annual cardiac mortality is associated with residence in colder regions of Sweden. Try as they might, the authors could not support the current paradigm for heart disease. They failed to mention that cold weather is a marker for low vitamin D levels, as outdoor activity in cold weather is both curtailed and requires extensive clothing.
Scott Med J. 1991 Dec;36(6):165-8.
The point of these six paradoxes is simple. Our current paradigm for understanding heart disease is incomplete. One or more major causes of heart disease remain unknown. The theory that vitamin D deficiency is one of those major causes certainly helps to explain these paradoxes.
7. A professor named Robert Scragg first proposed that vitamin D deficiency plays a role in cardiovascular disease.
A. True
B. False
True. For the last 25 years Dr. Scragg, Associate Professor in Epidemiology at the University of Auckland, has been trying to convince anyone who would listen that vitamin D explains many of observations about heart disease, such as: incidence of heart disease is higher at higher latitudes, at lower altitudes, and in the winter. It is also higher in black individuals as well as in older, inactive, and obese patients. Yet, vitamin D blood levels are lower in all these, with altitude being the least known of these associations. The age adjusted mortality for heart disease in the United States showed a striking inverse correlation with altitude in 1979, before the sun scare. American populations at the highest altitude had about half the heart disease of sea level populations. Thirty-five years ago, Leaf observed that most of the long-lived populations in the world reside at high altitude.
Int J Epidemiol. 1981 Dec;10(4):337-41.
J Chronic Dis. 1979;32(1-2):157-62.
Sci Am. 1973 Sep;229(3):44-52.
8. Higher vitamin D levels are associated with lower risk for heart attack.
A. True
B. False
True. Dr. Scragg's research revealed this in 1990. In 1979, the Tromso Heart Study found that by correcting low vitamin D levels the risk for heart attack was lowered.
Int J Epidemiol. 1990 Sep;19(3):559-63.
Br Med J. 1979 Jul 21;2(6183):176.
9. A scientist would never publish a study that appears to disprove his own theory.
A. True
B. False
False. Dr. Scragg did publish such a study. He discovered that a single oral dose of 100,000 units of vitamin D had no effect on risk factors (serum cholesterol or blood pressure) five weeks after publishing the study above. This seemed to disprove his theory, but he published the data anyway-always the mark of a good scientist. We now know that 100,000 units are a small dose and that "stoss" therapy is not physiological. Such a small single dose will raise vitamin D levels for a month or two, but then they rapidly fall towards baseline and would have little physiological effect five weeks later.
Eur J Clin Nutr. 1995 Sep;49(9):640-6.
10. Vitamin D can be used in the treatment of and prevention of heart disease.
A. True
B. False
True. It reduces vascular calcification and vascular smooth muscle proliferation. It also decreases parathormone levels and renin, and reduces CRP and other markers of inflammation. In 2005, Zitterman proposed vitamin D deficiency to be connected to heart disease. This explains the excess cardiovascular deaths at high latitude, low altitude, and during the winter. It also explains the higher incidence of heart disease in blacks and individuals who are older, inactive, and obese, as these groups usually have significantly lower vitamin D blood levels.
Br J Nutr. 2005 Oct;94(4):483-92.
11. Patients with congestive heart failure (CHF) have very low levels of vitamin D.
A. True
B. False
True. Zittermann discovered this in 2003. He found that protein NT-proANP, which is a predictor of CHF severity, was inversely associated with vitamin D levels.
J Am Coll Cardiol. 2003 Jan 1;41(1):105-12.
12. Blood cholesterol measurements are worse at higher latitudes, lower altitudes, and in the winter.
A. True
B. False
True. The effects of latitude on cholesterol seen in the first study are quite remarkable. In the Greek study, total serum cholesterol for both men and women were significantly lower at higher altitude in spite of similar diets. The seasonal variations in cholesterol are well known and not explained by seasonal dietary changes.
QJM. 1996 Aug;89(8):579-89.
J Epidemiol Community Health. 2005 Apr;59(4):274-8.
J Clin Epidemiol. 1988;41(7):679-89.
Chronobiol Int. 2001 May;18(3):541-57.
13. Blood pressure is higher at higher latitudes, lower altitudes, in the winter.
A. True
B. False
True. It is also usually higher in blacks, the aged, and the obese. High blood pressure is one of the strongest predictors of heart disease. Here, six facts about hypertension can be explained by one theory: vitamin D.
Hypertension. 1997 Aug;30(2 Pt 1):150-6.
Ann Hum Biol. 2000 Jan-Feb;27(1):19-28.
Harv Health Lett. 2005 Sep;30(11):8.
14. Diabetes is more common at higher latitudes, lower altitudes, in black, aged, and obese individuals.
A. True
B. False
True. Both blood sugar and hemoglobin A1c are higher in the winter.
Eur J Epidemiol. 1991 Jan;7(1):55-63.
Nutrition. 2001 Apr;17(4):305-9.
Diabetes Res Clin Pract. 2005 Aug;69(2):169-74. Epub 2005 Jan 12.
Diabetologia. 1982 Apr;22(4):250-3.
Am J Epidemiol. 2005 Mar 15;161(6):565-74.
15. Vitamin D has been shown to significantly reduce C-reactive protein (CRP), which may be a better predictor of heart disease than LDL cholesterol.
A. True
B. False
True. A Belgian study found a significant reduction in CRP, even though their high-dose vitamin D group received only 500 units a day.
QJM. 2002 Dec;95(12):787-96.
J Clin Endocrinol Metab. 2003 Oct;88(10):4623-32.
16. The risk for total mortality is significantly lower in subjects with high vitamin D levels.
A. True
B. False
True. However, the study that determined this is in Finnish and has not been translated into English (author communication).
Seppanen R, Marniemi J, Alanen E, Impivaara O, Jarvislo J, Ronnemaa T, et al. Ravinnon ja seerumin vitamiinit ja kivennaisaineet vanhusten kuolleisuuden ennustajina. Suom Laakaril 2000;42:4255-60 [Finnish]. Reported in Nutr Metab Cardiovasc Dis. 2005 Jun;15(3):188-97.
17. It is now a proven scientific fact that vitamin D both prevents and treats heart disease.
A. True
B. False
False. Like so may other fields of vitamin D research, we lack the definitive interventional trials that would settle the point. It would be simple for the National Institutes of Health to fund a study giving physiological doses of real vitamin D (5,000 units of cholecalciferol) to heart disease patients for a year and see if CRP, proinsulin, blood pressure, cholesterol, body weight, heart attacks, and/or death rates decrease.
We will have to wait years for science to find out if vitamin D prevents and/or treats heart disease. Although, while you are waiting, you do have a choice. You can wait vitamin D deficient (levels less than 40 ng/mL) or you can wait vitamin D sufficient (levels around 40–60 ng/mL). The choice is yours-another Pascal's Wager-this time you are betting your heart.
Also, while we wait for more studies, remember that vitamin D should be obtained daily-not monthly or weekly. It should be obtained physiologically and not in an all-then-none manner, as would happen if you took 100,000 units one day a month and nothing the other 29 days. It appears likely that high blood levels followed by low blood levels may do harm. The reason is that falling blood levels reset the enzymes maintaining intracellular levels of activated vitamin D, resulting in low intracellular levels.
Int J Cancer. 2004 Sep 1;111(3):468; author reply 469.
Vitamin D should be consumed the way the human genome consumed it during its evolution in subequatorial Africa, a steady amount every day. If you live down south, you can go in the sun for a few minutes every day. Up north, you can sun in the warmer months and in the winter either use a sunlamp or take vitamin D cholecalciferol. Adults in the north could take one 5,000 unit capsule a day in late fall, winter, and early spring; less in the late spring and early fall; and none in the summer months-depending on your sunning habits. Children over 50 pounds need two of the 1,000 unit capsules every day in the colder months while children under 50 pounds need about 1,000 units in the colder months. Few people need to take oral vitamin D in the summer (unless you are a sunphobe). Get enough vitamin D every day to maintain stable vitamin D blood levels, around 50 ng/mL, year-round.
One last question: should patients dying from heart disease be allowed to die vitamin D deficient? According to the current paradigm, the answer appears to be yes, for none of the cardiologists I know even bother to check a vitamin D level. Given the scientific literature, that's a bit paradoxical.
John Cannell, MD
www.cholecalciferol-council.com
9100 San Gregorio Road
Atascadero, CA 93422
USA
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The above text originates from a periodic newsletter from the Vitamin D Council (www.cholecalciferol-council.com) which is a non profit organization which attempts to put an end to the epidemic of vitamin D deficiency.
This newsletter is not protected by copyright and may be reproduced it its unaltered form via the internet.
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