Vitamin D versus lowering cholesterol to prevent heart failure:
Jacob Schor, ND, FABNO
August 19, 2008
Returning from our relaxing week at the Arizona Biltmore at the annual convention of the American Association of Naturopathic Physicians, I found an appreciative letter from a patient. Actually a patient’s wife, who was thrilled that her husband’s cholesterol had come down to 217 from a reading of 239 back in June. She’s thrilled, her husband is thrilled, apparently even their MD finds is thrilled.
The only one unimpressed is me.
I want to say, “Big Deal.” But with sarcasm. Decreasing one’s cholesterol levels has ridiculously little effect on health. One certainly won’t feel any better. This ‘miraculous improvement, even if we were to get below 200 may decrease this gentleman’s overall risk of having a fatal heart attack by only a few percentage points, perhaps a 2% decrease in risk. Not much of a change when we compare this to other interventions such as eating nuts or fish each week, either of which cut risk by half, or 50%.
There is a new paper, posted online August 5 and that is scheduled for publication in the Journal of Clinical Endocrinology and Metabolism. Stefan Pilz and his colleagues at the Department of Public Health, Social and Preventative Medicine at the University of Heidelberg in Germany, looked for associations between vitamin D deficiency, heart failure and sudden cardiac death. Sudden cardiac death is medical language for dropping dead of a heart attack.
The researchers followed 3,316 people for a period of almost 8 years and tracked their vitamin D levels and tracked who died of heart problems. Over the course of the study 116 people died of heart failure and 188 of heart attacks. There was a clear inverse association between vitamin D and dying. After adjusting for other cardiovascular risk factors they were able to calculate hazard ratios for different levels of vitamin D.
Patients with severe deficiency, defined as less than 10ng/ml on the 25(OH)D test had risk ratios of 2.8 for heart failure and 5.05 for sudden cardiac death when compared with people with vitamin D levels > 30 ng/ml. The means these people deficient in D were about three times as likely to die of heart failure and five times as likely to die of heart attacks than people with what we consider OK levels.
This is huge. Lowering someone’s cholesterol from 230 to below 200 may possibly reduce a man’s risk of sudden cardiac death by 2%. Last time I looked there was no data to show that it has any protective benefit in women. On the other hand, increasing someone’s vitamin D level from below 10 to above 30 reduces risk by a factor of 5. Think 500% difference.
The full text of this study can be downloaded for free at:
How common is it to be this deficient? We often see patients in our practice close to this low, below 20 is not rare.
Dr Sunny Linnebur (I kid you not, that is her name) of the University of Colorado is our best source of information about prevalence of vitamin D deficiency in Denver. In March of 2007 the American Journal of Pharmacotherapy published her research on vitamin D levels in the elderly in Denver. She defined vitamin D deficiency as below 32 ng/ml, a level that is generally accepted as the cutoff to what is acceptable. Collecting data on 80 older people, average age almost 79, she found that 59 of them (74%) were deficient.
Testing for vitamin D deficiency doesn’t cost much more than testing for cholesterol. Low levels of vitamin D, enough to increase cardiovascular disease risk are as common, if not more so, than elevated cholesterol. From these numbers it would appear that correcting vitamin D deficiency would have a greater impact on morbidity and mortality than correcting cholesterol. If we are to believe these numbers, a 2% versus 500% decrease in sudden cardiac death.
What’s the problem then? The only explanation I can see for the disparity of attention given to vitamin D versus cholesterol is the profit. Treating cholesterol requires regular use of expensive patented drugs. Correcting vitamin D deficiency requires more sun exposure or if profoundly deficient, inexpensive vitamin supplements.
The drugs used to lower cholesterol come with side effects. The most common is leg pain with walking. The worse case scenario is that this leg pain progresses to rhabdomylolysis, rather than pain, the actual destruction of the muscle. Current medical literature does not report side effects from supplementing with vitamin D. Of course there are other benefits that we have mentioned elsewhere.
I wrote about this cholesterol business last summer after reading Overdosed America and meeting the author, John Abramson:
A nice and easy to read on Vitamin D appeared in the Globe and Mail earlier this year:
And we have certainly sent out numerous articles over the years:
J Clin Endocrinol Metab. 2008 Aug 5. [Epub ahead of print]
Association of vitamin D deficiency with heart failure and sudden cardiac death in a large cross-sectional study of patients referred for coronary angiography.
Pilz S, März W, Wellnitz B, Seelhorst U, Fahrleitner-Pammer A, Dimai HP, Boehm BO, Dobnig H.
Department of Public Health, Social and Preventive Medicine, Mannheim Medical Faculty, University of Heidelberg, Mannheim, Germany (Pilz, März); Department of Internal Medicine, Division of Endocrinology and Nuclear Medicine, Medical University of Graz, Austria (Pilz, Fahrleitner-Pammer, Dimai, Dobnig); Synlab Center of Laboratory Diagnostics, Heidelberg, Germany (März); LURIC Study nonprofit LLC, Freiburg, Germany (Wellnitz, Seelhorst); Department of Internal Medicine I, Division of Endocrinology and Diabetes, Ulm University, Germany (Boehm).
Context: Vitamin D has been shown to influence cardiac contractility and myocardial calcium homeostasis. Objectives: We aimed to elucidate whether insufficient vitamin D status is associated with heart failure and sudden cardiac death (SCD). Design, Setting and Participants: We measured 25-hydroxyvitamin D [25(OH)D] levels in 3299 Caucasian patients who were routinely referred to coronary angiography at baseline (1997-2000). Main outcome measures: Cross-sectional associations of 25(OH)D levels with measures of heart failure and Cox proportional hazard ratios for deaths due to heart failure and for SCD according to vitamin D status. Results: 25(OH)D was negatively correlated with N-terminal pro-B-type natriuretic peptide (NT-pro-BNP), and was inversely associated with higher NYHA classes and impaired left ventricular function. During a median follow-up time of 7.7 years, 116 patients died due to heart failure and 188 due to SCD. After adjustment for cardiovascular risk factors, the hazard ratios (with 95% confidence intervals) for death due to heart failure and for SCD were 2.84 (1.20-6.74) and 5.05 (2.13-11.97), respectively, when comparing patients with severe vitamin D deficiency [25(OH)D < 25 nmol/L)] with persons in the optimal range [25(OH)D >/= 75 nmol/L]. In all statistical analyses we obtained similar results with 25(OH)D and with 1,25-dihydroxyvitamin D [1,25(OH)2D]. Conclusions: Low levels of 25(OH)D and 1,25(OH)2D are associated with prevalent myocardial dysfunction, deaths due to heart failure and SCD. Interventional trials are warranted to elucidate whether vitamin D supplementation is useful for treatment and/or prevention of myocardial diseases.
Am J Geriatr Pharmacother. 2007 Mar;5(1):1-8.
Prevalence of vitamin D insufficiency in elderly ambulatory outpatients in Denver, Colorado.
Linnebur SA, Vondracek SF, Vande Griend JP, Ruscin JM, McDermott MT.
Department of Clinical Pharmacy, University of Colorado at Denver and Health Sciences Center; Denver, Colorado 80262, USA. firstname.lastname@example.org
BACKGROUND: Vitamin D insufficiency is common in the elderly. However, previous studies have utilized 25-hydroxvvitamin D (25[OH]D) concentrations as low as <16 ng/mL for defining vitamin D insufficiency. Moreover, most of the studies have been conducted in European patients, in certain geographic areas of the United States, or in institutionalized elderly. OBJECTIVE: The goal of this study was to characterize vitamin D concentrations in ambulatory elderly living in metropolitan Denver, Colorado, utilizing 25(OH)D concentrations <32 ng/mL as the definition for vitamin D insufficiency. METHODS: Ambulatory older adults (aged 65-89 years) with clinic visits during December 2005 and January 2006 were enrolled. Serum concentrations of 25(OH)D, parathyroid hormone (PTH), calcium, phosphorus, creatinine, and albumin were measured; height and weight were also measured. Data regarding dietary and over-the-counter vitamin D intake were collected, as well as information on body mass index, history of osteoporosis, osteoporosis treatment, and history of falls and fractures. RESULTS: Eighty patients (mean [SD] age, 77.8 [5.3] years; age range, 66-89 years) completed the study; there were no dropouts. The majority of patients were white (88%) and female (68%). Fifty-nine (74%) were found to have vitamin D insufficiency. Mean total and over-the-counter vitamin D intake was significantly higher in sufficient (P < 0.01) and insufficient (P < 0.05) patients compared with deficient patients, but dietary intake did not differ significantly between groups. The majority of patients who were vitamin D insufficient consumed more than the recommended 400 to 600 IU/d of vitamin D. Obese patients were found to have significantly lower 25(OH)D concentrations (P < 0.001) and higher PTH concentrations (P = 0.04) than nonobese patients. CONCLUSIONS: Vitamin D insufficiency is prevalent in ambulatory, and especially obese, elderly living in Denver, Colorado, despite vitamin D intake consistent with national recommendations. Dietary intake of vitamin D appeared to be unreliable to prevent insufficiency. Based on our results, along with other published data, we feel that national recommendations for vitamin D intake in the elderly should be increased to at least 800 to 1000 IU/d of over-the-counter supplemental cholecalciferol.