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Content 7


The Doctor and the Pharmacist

Radio Show Articles:
November 19, 2011

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Obesity Management in Primary Care Shown Feasible — Though Costs Unknown
Supreme Court to Review Healthcare Law
Some Benefit Reported with Yoga for Chronic Low Back Pain
Light-Activated Nanosutures: Wound Healing for the 21st Century
When BRCA Mutations Run in the Family, Should Noncarriers Worry?
Reversing the Adverse Cardiovascular Effects of Childhood Obesity Later in Life
Does Sugary Soda Make Youth Violent?
Niacin Is Ineffective in Patients with Established Cardiovascular Disease
Many Teens with Polycystic Ovarian Syndrome Screen Positive for Sleep Problems
Estradiol Vaginal Ring vs. Oral Oxybutynin for Overactive Bladder
Gastrointestinal Bleeding with Low-Dose Aspirin
Vitamin D Lack Linked to Women’s Heart Failure

MM: Here is an example of government funding supporting planned failure. We have heard that the definition of insanity is to repeat the same act and expect a different result. The methods used in these studies have historically shown nominal results or completely failed yet they are being repeated and FEDERALLY FUNDED! What nonsense. Let the FEDS fund a HCG study and compare the results or better yet, take the information from our thousands of patients and look at the results. We have demonstrated clinically that there is a cost-effective and clinically effective way to lose and control weight thereby improving all the symptoms and associated complications of Metabolic Syndrome.
Obesity Management in Primary Care Shown Feasible — Though Costs Unknown
     Two federally sponsored studies examining the primary care management of obesity show that it's indeed possible, but the cost-effectiveness remains unknown. Both were presented at the American Heart Association meeting and appear in the New England Journal of Medicine.
     One study randomly assigned some 400 patients to usual care (quarterly office visits), lifestyle counseling (quarterly visits plus monthly sessions with lifestyle coaches), or enhanced care (visits, coaching, plus meal replacements or weight-loss medication). By the end of the 2-year trial, mean weight loss was greater with enhanced care (4.6 kg) than with lifestyle counseling (2.9 kg) or usual care (1.7 kg).
     Another study randomized a separate cohort of 400 patients across three interventions: self-directed care, remote support (through the Web), and remote support plus occasional in-person support. At 2 years, both remote-support groups showed greater mean weight loss than the self-directed care group (5.1 kg with remote and in-person support, 4.6 kg with remote support only, 0.8 kg with self-directed care).
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Supreme Court to Review Healthcare Law
     The Supreme Court announced that it will hear challenges to the new healthcare law. The result of the ruling may provide insight as to the federal government's power to address pressing social problems, specifically how to ensure medical coverage nationwide. The main question is whether Congress exceeded its power to regulate interstate commerce by requiring most Americans to buy insurance by 2014 or face a tax penalty.
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MM: Yoga and aggressive stretching may not significantly decrease chronic low back pain (LBP) but I have seen both personally and in my patients over the past 30 years that gentle, controlled stretching on a daily basis frequently makes a difference in lower back pain, mobility and even bowel regularity. The bottom line is that people with LBP tend to move less and any increase in movement is going to improve quality of life.
Ann Intern Med 2011 Nov 1; 155:569.
Some Benefit Reported with Yoga for Chronic Low Back Pain
Back function, but not pain, was better with yoga.
     Does yoga benefit people with chronic or intermittent low back pain (LBP)? In a U.K. study, researchers randomized 313 adults with LBP (mean duration, 10 years) to 12 weekly yoga sessions or usual care.
     Sixty percent of yoga-randomized patients attended at least six classes; 15% failed to attend a single class. At 3 and 12 months, functional ability scores on a 24-point instrument improved by a mean of 2.2 points in the yoga group and by 1.6 points in the usual-care group. Pain scores did not differ between groups. Five patients reported worsened back pain that might have been secondary to yoga participation.
     Comment: Particularly because the mean duration of LBP among participants in this study was 10 years, and the intervention lasted only 12 weeks, the modest improvement in function among yoga participants relative to usual-care patients was notable. Although yoga failed to reduce pain, it still might be useful to recommend it to patients, given its relative safety.
Jamaluddin Moloo, MD, MPH Published in Journal Watch General Medicine November 17, 2011
     Citation(s):Tilbrook HE et al. Yoga for chronic low back pain: A randomized trial. Ann Intern Med 2011 Nov 1; 155:569. (http://annals.org/content/155/9/569.full)
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MM: This article tickled my nerd fancy. How cool is it to paint an inactive compound on an incision and then shine a light on it to get a superior suture than a staple or a needle with thread? This type of technology almost had to have been developed by a Star Trek & Dr Bones McCoy fan.
Brit J Dermatol 2011 Oct 27
Light-Activated Nanosutures: Wound Healing for the 21st Century
Molecular protein-to-protein cross-links were formed between tissue surfaces with a combination of laser and photosensitizing dye.
     The use of suture material for wound closure dates back to at least 3000 BC. Although there have been refinements, little progress has been made in developing entirely new procedures. These investigators employed a novel process, photoactivated tissue bonding (PTB), for the closure of cutaneous wounds from surgical excisions. The procedure is as follows: The dye rose bengal is applied to both surfaces of a wound. Alone, this compound is biologically inactive, but exposure to green light (532 nm; in this study, from a KTP laser) initiates a photochemical reaction that rapidly produces covalent cross-links between collagen molecules. Unlike typical sutures, light-activated tissue bonding produces little inflammation.
     In this first human study, 31 wounds from surgical excision of skin lesions on the abdomen, back, forearm, shoulder, upper arm, and thigh were evaluated. Half of each wound was closed with 4-0 nylon nonabsorbable sutures, and the other half with PTB. Trained observers assessed healing directly and by photographs at 2 weeks and 6 months. At 2 weeks, the PTB side showed less erythema, crusting, and oozing than the sutured side, and the observers rated the PTB side superior in appearance (P<0.001). Wound dehiscence was not observed with either closure technique. At 6 months, appearance was rated superior in 77% of the PTB-closed sides (P>0.001), and sutures were associated with wider scars. Patient satisfaction in scar appearance was also greater in the PTB treated area, both at 2 weeks and at 6 months.
     Comment: This is a wonderful example of how biotechnology can be used to improve medical processes. Superior appearance may be particularly attractive (no pun intended) for closure of lesions on the face, where it is of paramount importance. It would not be surprising if the use of light with a photosensitizer also has an antimicrobial effect, thereby reducing the incidence of wound infections. Although additional studies are required to determine applicability (cost, suitable wound types, equipment requirements, and time required to close wounds), the concept is innovative, makes biological sense, and represents a conceptual advance in wound healing.
Craig A. Elmets, MD Hensin Tsao, the husband of the lead author and an author of the present study, is the Editor-in-Chief of Journal Watch Dermatology. Dr. Tsao had no role in the selection, writing, or review of this summary.
Published in Journal Watch Dermatology November 18, 2011
     Citation(s): Tsao S et al. Light activated tissue bonding for excisional wound closure: A split-lesion clinical trial. Brit J Dermatol 2011 Oct 27; [e-pub ahead of print].
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J Clin Oncol 2011 Oct 31
When BRCA Mutations Run in the Family, Should Noncarriers Worry?
Population-based study shows that noncarriers are not at excess risk for breast cancer attributable to familial mutations.
     A key rationale of BRCA mutation testing is to guide counseling and recommendations for family members of women with breast cancer who test positive. Some studies have suggested that relatives of women who carry deleterious BRCA mutations but who themselves test negative are at excess risk for breast and ovarian cancer; however, other findings conflict. Investigators used data from population-based cancer registries in Australia, Canada, and Northern California to assess breast cancer risk in first-degree relatives (FDRs) of women with the disease. Registry participants with breast cancer were tested for BRCA1 and BRCA2 mutations; FDRs of identified mutation carriers also were tested (FDRs of women with breast cancer who tested negative for BRCA mutations were considered to be noncarriers).
     Among 3047 families, BRCA1 and BRCA2 mutations were detected in 160 and 132 families, respectively. Among FDRs who tested negative for family-specific BRCA mutations, risk for breast cancer was not significantly higher than that in FDRs from families without BRCA mutations. FDRs of women with non-BRCA breast cancer were at excess risk for this form of malignancy, implying a role for the aggregate contribution of polygenic (i.e., combined action of multiple genes with modest effects), as well as nongenetic risk factors within families.
     Comment: Often, a primary motivation in women who undergo BRCA mutation testing is to provide information that could help their relatives. This report confirms that noncarrier first-degree relatives of BRCA mutation–positive women are not themselves at excess risk for the disease and, therefore, can pursue breast cancer screening consistent with that in the general population.
Andrew M. Kaunitz, MD Published in Journal Watch Women's Health November 17, 2011
     Citation(s):Kurian AW et al. Breast cancer risk for noncarriers of family-specific BRCA1 and BRCA2 mutations: Findings from the Breast Cancer Family Registry. J Clin Oncol 2011 Oct 31; [e-pub ahead of print]. (http://dx.doi.org/10.1200/JCO.2010.34.4440)
Robson M. Do women remain at risk even if they do not inherit a familial BRCA 1/2 mutation? J Clin Oncol 2011 Oct 31; [e-pub ahead of print]. (http://dx.doi.org/10.1200/JCO.2011.37.6483)
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MM: The old saying, “Its never too late to start” might be echoed by, “Its never too early to start.” Obesity and its lifelong negative effects (hypertension, dyslipidemia and diabetes) are the number one causes of death and morbidity (illness) in North America and much of the rest of the planet. We have to start teaching our children at a young age what  proper nutritional and eating habits are.
N Engl J Med 2011 Nov 17; 365:1876
Reversing the Adverse Cardiovascular Effects of Childhood Obesity Later in Life
Results of four large long-term studies indicate that adults who were obese during childhood can lower their cardiovascular risk by not being obese as adults.
     Childhood obesity raises risk for obesity and cardiovascular disease during adulthood. To examine whether cardiovascular risks persist in obese children who are no longer obese as adults, researchers combined data from four longitudinal cohort studies (2 U.S., 1 Australian, and 1 Finnish) in which cardiovascular risk was tracked from childhood into adulthood in 6328 participants. Mean follow-up was 23 years, and adiposity status was based on body-mass index (BMI) measurements taken during childhood and adulthood.
     Obese adults — regardless of childhood adiposity status — had significantly higher risk for hypertension, dyslipidemia, and type 2 diabetes mellitus than did participants who had never been obese as children or adults. However, normal-weight adults — regardless of childhood adiposity status — had similar cardiovascular risk as participants who had never been obese. Results were similar for men and women when different definitions of childhood adiposity were used.
     As expected, subjects who were overweight or obese in both childhood and adulthood had significantly increased risks for type 2 diabetes, hypertension, dyslipidemia, and carotid-artery atherosclerosis, compared with adults who were never obese. However, subjects who were overweight or obese in childhood and then became nonobese as adults had similar risks as those who were never obese.
     Comment: These results suggest that obese children can lower their risk for cardiovascular disease if they achieve normal BMIs as adults. Therefore, it's never too late to encourage healthy lifestyles in our patients. We must identify the most effective interventions for preventing and treating childhood obesity as well as for helping patients maintain healthy weight as adults. As stated by an editorialist, "treating and preventing childhood obesity is a cost-effective way of achieving a long-term reduction in atherosclerotic cardiovascular disease."
Louis M. Bell, MD Published in Journal Watch Pediatrics and Adolescent Medicine November 16, 2011
     Citation(s): Juonala M et al. Childhood adiposity, adult adiposity, and cardiovascular risk factors. N Engl J Med 2011 Nov 17; 365:1876.
Rocchini AP. Childhood obesity and coronary heart diseases. N Engl J Med 2011 Nov 17; 365:1927.
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Inj Prev 2011 Oct 24
Does Sugary Soda Make Youth Violent?
Among Boston youth, greater consumption of carbonated non-diet soft drinks was associated with an increased likelihood of carrying weapons or being violent towards others.
     Some evidence suggests that consumption of sugary soft drinks is associated with adverse mental health outcomes. To explore whether soft drinks are also associated with violent behavior, investigators analyzed data from 1618 9th to 12th grade students in Boston public schools who reported how much soda they consumed during the past 7 days (students were specifically instructed not to include diet soda). They also reported if they had carried a gun or knife in the past year and if they had been violent towards peers, siblings, or dates during the past month.
     In analysis controlled for sex, age, ethnicity, body-mass index (BMI), past-month alcohol or tobacco use, past-week family dinners, and less than 6 hours of sleep on average school nights, consumption of greater quantities of soda was significantly correlated in a dose-response relation with each measure of violence. For example, among youth who consumed up to 1 can of soda per week, 23% reported carrying a gun or a knife and 15% reported being violent in a dating relationship, compared with 38% and 25%, respectively, of those who reported drinking 5 to 7 cans per week, and 43% and 27%, respectively, of those who reported drinking 14 or more cans per week. In separate regression models for each outcome, drinking 5 or more cans of soda per week was a highly significant predictor of each of the four outcomes; only tobacco and alcohol use were stronger predictors in some cases.
     Comment: Wouldn't it be wonderful if the solution to youth violence was to remove nondiet soft drinks from adolescent diets? The authors controlled for a number of potential confounders and a dose-response relation emerged, so it is possible that sugar or one of the other ingredients in sodas (caffeine, sodium benzoate, food coloring, phosphoric or citric acid) might be linked with violent behavior. But a much more likely explanation is that sugary soda consumption is a marker for an unmeasured biological, social, or environmental variable that is linked to these outcomes. Even so, given that some studies have linked consumption of these drinks to obesity, encouraging adolescents to give up sugary sodas might be worthwhile and have a bigger payoff than previously thought.
Alain Joffe, MD, MPH, FAAP Published in Journal Watch Pediatrics and Adolescent Medicine November 16, 2011
     Citation(s):Solnick SJ and Hemenway D. The ‘Twinkie Defense': The relationship between carbonated non-diet soft drinks and violence perpetration among Boston high school students. Inj Prev 2011 Oct 24; [e-pub ahead of print].
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N Engl J Med 2011 Nov 15
Niacin Is Ineffective in Patients with Established Cardiovascular Disease
Niacin plus simvastatin was no better than simvastatin alone.
     Physicians sometimes prescribe niacin for statin-treated patients to raise HDL cholesterol levels or to manipulate lipid subfractions detected by more elaborate lipid testing. However, the clinical effect of this practice is unclear. In the NIH-sponsored AIM-HIGH study, 3414 patients with established cardiovascular disease were randomized to receive simvastatin plus either extended-release niacin or placebo. Enrollment criteria included HDL cholesterol levels <40 mg/dL for men and <50 mg/dL for women, and triglyceride levels between 150 and 400 mg/dL. Patients were selected for randomization only after completing an open-label run-in phase, during which they demonstrated that they could tolerate high niacin doses (1500–2000 mg daily). During the trial, most patients took 40-mg or 80-mg simvastatin daily; the LDL cholesterol target was <80 mg/dL. Most patients also received aspirin, β-blockers, and angiotensin-converting–enzyme inhibitors.
     Compared with placebo, niacin therapy induced significant changes in LDL cholesterol, HDL cholesterol, and triglyceride levels. Nevertheless, the trial was stopped after average follow-up of 3 years when no hint of cardiovascular benefits and a trend toward more strokes with niacin were reported. The primary outcome (a composite of adverse coronary events, strokes, and revascularization) occurred in 16% of patients in each group; the incidence of stroke was 1.7% with niacin and 1.1% with placebo (P=0.09).
     Comment: These results — first announced in May 2011 (JW Gen Med Jun 7 2011) — are straightforward: Extended-release niacin doesn't benefit patients with known cardiovascular disease who achieve low LDL cholesterol levels with statin monotherapy (the average LDL cholesterol level in this study's statin-plus-placebo group was about 70 mg/dL). Note that this study was purely a secondary prevention trial; we also have no evidence that niacin improves outcomes in contemporary primary prevention.
Allan S. Brett, MD Published in Journal Watch General Medicine November 15, 2011
     Citation(s): The AIM-HIGH Investigators. Niacin in patients with low HDL cholesterol levels receiving intensive statin therapy. N Engl J Med 2011 Nov 15; [e-pub ahead of print]. (http://www.nejm.org/doi/full/10.1056/NEJMoa1107579)
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J Pediatr 2011 Sep; 18:962
Many Teens with Polycystic Ovarian Syndrome Screen Positive for
Sleep Problems

About half of adolescents with PCOS screened positive for sleep-disordered breathing or excessive daytime sleepiness.
     Adult women with polycystic ovarian syndrome (PCOS) have high rates of sleep-disordered breathing (SDB), but whether adolescents do too is unclear. Investigators compared the prevalence of SDB and excessive daytime sleepiness (EDS) in 103 girls with PCOS (age range, 13–18 years; 56% Hispanic and 29% black) and 90 girls without PCOS matched for age, race, and body-mass index (BMI)-z scores from adolescent and obesity clinics at the same hospital. SDB was assessed with the Pediatric Sleep Questionnaire-Sleep-Related Disordered Breathing scale, which has been previously validated in this age group. EDS was assessed with a modified version of the Epworth Sleepiness Scale, which has not been validated in teens.
     Significantly more girls with PCOS than controls screened positive for SDB (46% vs. 28%) and EDS (54% vs. 36%). Among girls with PCOS, those who screened positive for SDB and EDS had significantly higher fasting insulin levels and insulin resistance (but not fasting glucose or free and total testosterone levels) than those without evidence of sleep-related problems. In regression analysis, BMI-z score was not associated with SDB or EDS.
     Comment: PCOS is a complex endocrine disorder, and treatment has focused on correcting or ameliorating the androgen excess, insulin resistance, and obesity that characterize it. Although the scale used to screen girls for EDS has not been validated in teens, the findings suggest that we should add careful screening and judicious referral for SDB to our management of girls with PCOS. The finding that BMI-z score was not related to risk for SDB indicates that we cannot use BMI alone to identify which girls with PCOS are at risk for SDB.
Alain Joffe, MD, MPH, FAAP Published in Journal Watch Pediatrics and Adolescent Medicine November 2, 2011
     Citation(s):Nandalike K et al. Screening for sleep-disordered breathing and excessive daytime sleepiness in adolescent girls with polycystic ovarian syndrome.
J Pediatr 2011 Oct; 159:591.
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Menopause 2011 Sep; 18:962
Estradiol Vaginal Ring vs. Oral Oxybutynin for Overactive Bladder
Both treatments were equally effective at diminishing urinary frequency.
     Overactive bladder (urinary urgency and frequency with or without urge incontinence) affects as many as 40% of postmenopausal women. Behavior modification, pelvic floor exercises, and anticholinergic agents (e.g., oxybutynin chloride) are among first-line therapies; however, because side effects are common with such agents, topical estrogens are sometimes prescribed instead. In a manufacturer-funded, 12-week, randomized study, 59 postmenopausal women with urgency and frequency received either the ultralow-dose estradiol vaginal ring (Estring; 7.5 µg 17β-estradiol released daily) or oral oxybutynin (5 mg twice daily).
     Women in both groups had similar decreases in number of voids during a 24-hour period (from a mean of 14.9 to 10.4 for the vaginal ring [P<0.001] and from a mean of 14.7 to 11.7 for oxybutynin [P=0.003]) and similar significant improvements in quality of life. Therapy was discontinued by four vaginal ring recipients because of difficulty retaining the rings, and by four oxybutynin recipients because of adverse effects. At trial's end, 85% of ring users and 59% of oxybutynin users reported wanting to continue their assigned therapies (P=0.035).
     Comment: This study documents the effectiveness of the ultralow-dose estradiol vaginal ring for treating women with overactive bladder. Because the ring lacks the side effects of anticholinergic agents — and is inserted just once every 12 weeks — this treatment could appeal to many women. As noted by an editorialist, the vaginal ring is more expensive than either oxybutynin or estradiol vaginal cream, but some women might consider the higher cost to be worth it.
Robert W. Rebar, MD Published in Journal Watch Women's Health October 13, 2011
     Citation(s):Nelken RS et al. Randomized trial of estradiol vaginal ring versus oral oxybutynin for the treatment of overactive bladder. Menopause 2011 Sep; 18:962.
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Clin Gastroenterol Hepatol 2011 Sep; 9:762
Gastrointestinal Bleeding with Low-Dose Aspirin
A meta-analysis supports evidence of increased risk for GI bleeding from low-dose aspirin alone and in combination with clopidogrel or anticoagulants.
     Aspirin in low doses (75–325 mg/day) is commonly used as secondary prophylaxis after cardiovascular thrombotic events. However, its value for primary prophylaxis is unclear because of evidence that it increases the risk for gastrointestinal bleeding.
     To evaluate the risk for GI bleeding from low-dose aspirin alone or in combination with anticoagulants, clopidogrel, or proton-pump inhibitors (PPIs), investigators performed a meta-analysis of data from randomized controlled studies of any population taking low-dose aspirin on a daily basis. They identified 61 studies: 35 trials of aspirin alone, 18 with anticoagulants, 5 with clopidogrel, and 3 with PPIs.
     The pooled analysis showed that low-dose aspirin alone slightly decreased all-cause mortality (relative risk, 0.93; 95% confidence interval, 0.87–0.99) but increased the risk for major GI bleeding (odds ratio, 1.55; 95% CI, 1.27–1.90). In combination with clopidogrel or anticoagulants, the risk for major bleeding was higher than with aspirin alone (OR, 1.86; 95% CI, 1.49–2.31 and OR, 1.93; 95% CI, 1.42–2.61, respectively). Conversely, PPI use together with aspirin decreased the likelihood of bleeding (OR, 0.34; 95% CI, 0.21–0.57).
     Comment: The results of this analysis support findings of prior observational studies that showed increased risk for GI bleeding with use of low-dose aspirin — a risk that was further increased with concomitant use of anticoagulants or clopidogrel but reduced in combination with PPIs. The current study is hampered by the difficulty of combining studies of heterogeneous designs, doses, and endpoints. Ultimately, studies with more-rigorous designs and endpoints will be required to enable us to more effectively balance the risk and benefits of low-dose aspirin therapy in various patient populations.
David J. Bjorkman, MD, MSPH (HSA), SM (Epid.) Published in Journal Watch Gastroenterology November 18, 2011
     Citation(s):Lanas A et al. Low doses of acetylsalicylic acid increase risk of gastrointestinal bleeding in a meta-analysis. Clin Gastroenterol Hepatol 2011 Sep; 9:762.
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November 17, 2011
Vitamin D Lack Linked to Women’s Heart Failure
Women with low vitamin D levels had a higher chance of heart failure; results affirm
prior findings

by Craig Weatherby
     Heart failure is an all-too-common condition in which the heart can’t pump enough blood to meet the body’s needs. Also known as congestive heart failure (CHF), this condition afflicts nearly six million people in the U.S., and kills some 300,000 Americans annually. Over time, the heart-muscle cells of people with CHF begin to weaken, work erratically, and eventually die. CHF is the leading reason why people aged 65 and older become hospitalized. Prior research indicates that the omega-3s in fish reduce risk of CHF (see the “Omega-3s & Heart Health” section of our news archive. In fact, omega-3s seem to help CHF more than statin-type heart drugs can (See “Heart Failure Findings Favor Omega-3s over Statin Drug”). And a fast-growing body of evidence associates healthy vitamin D levels with reduced risk of heart disease and its adverse outcomes … see the “Vitamin D & Heart Health” section of our news archive.

Last fall, headlines resulted from two large population studies, which found that Utah residents with the lowest blood levels of vitamin D had the worst cardiac health outcomes … with the lowest risk seen in those with the highest vitamin D levels:

And last summer, Danish researchers reported that among 148 CHF patients, higher vitamin D levels were associated with lower risk of death, independent of all other known risk factors (Schierbeck LL et al. March/June, 2011). The same Danish team conducted a similar – but much larger – study in women and just presented their findings at the American Heart Association meeting in Orlando, Florida (Schierbeck LL et al. Nov., 2011).

Danish study finds lower heart failure risk in women with higher vitamin D levels
Researchers led by Dr. Louise Schierbeck of Hvidovre Hospital followed 2,016 healthy women aged 45 to 58 for 16 years. Of the women with vitamin D deficiency – defined as blood levels below 20 nanograms per milliliter (ng/mL) – 15 percent had heart failure, heart attack, stroke, or died, compared with 10 percent of those with adequate amounts. As they wrote, “Healthy women with vitamin D insufficiency have a significantly increased risk of adverse cardiovascular outcome.” (Schierbeck LL et al. Nov., 2011)

Women with low vitamin D levels also had more cardiovascular risk factors than women with healthy levels. Compared with women who had higher vitamin D levels, those with low levels had significantly higher triglyceride levels, fasting glucose levels, BMIs, and significantly lower HDL (“good”) cholesterol levels.  Vitamin D expert Michael Holick M.D., Ph.D. – a professor of medicine, physiology and biophysics at Boston University – defines vitamin D deficiency as having less than 20 nanograms per milliliter (ng/mL) of blood and he defines vitamin D sufficiency as blood levels between 30 and 90 ng/mL.

As it happens, fatty wild fish like salmon, sardines, and tuna are excellent sources of omega-3s and vitamin D, making them the perfect heart-healthy protein foods. Farmed salmon has only one-quarter as much vitamin D as wild salmon, and while it has as many omega-3s, it is very high in omega-6 fatty acids. Omega-6 fatty acids compete with omega-3s for absorption and – when consumed in the extreme excess typical of American diets – promote inflammation and related diseases.
     Sources: European Society of Cardiology (ESC). Eating fatty fish and marine omega-3 fatty acids may reduce risk of heart failure. April 22, 2009. Accessed online at http://www.eurekalert.org/pub_releases/2009-04/esoc-eff042009.php, Freeman LM, Rush JE, Kehayias JJ, Ross JN Jr, Meydani SN, Brown DJ, Dolnikowski GG, Marmor BN, White ME, Dinarello CA, Roubenoff R. Nutritional alterations and the effect of fish oil supplementation in dogs with heart failure. J Vet Intern Med. 1998 Nov-Dec;12(6):440-8. http://circ.ahajournals.org/cgi/content/meeting_abstract/124/21_MeetingAbstracts/
A15113?sid=24e31dc8-137b-4587-9b29-13766a064f63; Kestenbaum B, Katz R, de Boer I, Hoofnagle A, Sarnak MJ, Shlipak MG, Jenny NS, Siscovick DS. Vitamin D, parathyroid hormone, and cardiovascular events among older adults. J Am Coll Cardiol. 2011 Sep 27;58(14):1433-41. Lau DH, Psaltis PJ, Carbone A, Kelly DJ, Mackenzie L, Worthington M, Metcalf RG, Kuklik P, Nelson AJ, Zhang Y, Wong CX, Brooks AG, Saint DA, James MJ, Edwards J, Young GD, Worthley SG, Sanders P. Atrial Protective Effects of n-3 Polyunsaturated Fatty Acids: A Long Term Study in Ovine Chronic Heart Failure. Heart Rhythm. 2010 Dec 7. [Epub ahead of print]; Levitan EB, Wolk A, Mittleman MA. Fatty fish, marine omega-3 fatty acids and incidence of heart failure. Eur J Clin Nutr. 2010 Mar 24. [Epub ahead of print] ; Levitan EB, Wolk A, Mittleman MA. Fish consumption, marine omega-3 fatty acids, and incidence of heart failure: a population-based prospective study of middle-aged and elderly men. Eur Heart J. 2009 Apr 21. [Epub ahead of print]; Liu LC, Voors AA, van Veldhuisen DJ, van der Veer E, Belonje AM, Szymanski MK, Silljé HH, van Gilst WH, Jaarsma T, de Boer RA. Vitamin D status and outcomes in heart failure patients. Eur J Heart Fail. 2011 Jun;13(6):619-25. Epub 2011 May 4. Mehra MR, Lavie CJ, Ventura HO, Milani RV. Fish oils produce anti-inflammatory effects and improve body weight in severe heart failure. J Heart Lung Transplant. 2006 Jul;25(7):834-8. Epub 2006 May 24. Mozaffarian D, Bryson CL, Lemaitre RN, Burke GL, Siscovick DS. Fish intake and risk of incident heart failure. J Am Coll Cardiol. 2005 Jun 21;45(12):2015-21. Mozaffarian D, Gottdiener JS, Siscovick DS. Intake of tuna or other broiled or baked fish versus fried fish and cardiac structure, function, and hemodynamics. Am J Cardiol. 2006 Jan 15;97(2):216-22. Epub 2005 Nov 21. Mozaffarian D, Lemaitre RN, Kuller LH, Burke GL, Tracy RP, Siscovick DS; Cardiovascular Health Study. Cardiac benefits of fish consumption may depend on the type of fish meal consumed: the Cardiovascular Health Study. Circulation. 2003 Mar 18;107(10):1372-7. Nodari S, Triggiani M, Campia U, Manerba A, Milesi G, Cesana BM, Gheorghiade M, Dei Cas L. Effects of n-3 Polyunsaturated Fatty Acids on Left Ventricular Function and Functional Capacity in Patients With Dilated Cardiomyopathy. J Am Coll Cardiol. 2010 Dec 29. [Epub ahead of print]; Schierbeck LL et al. Abstract 15113: Vitamin D And Cardiovascular Outcome in Healthy Postmenopausal Women. Circulation. 124:A15113. November 15, 2011. Accessed at Schierbeck LL, Jensen TS, Bang U, Jensen G, Køber L, Jensen JE. Parathyroid hormone and vitamin D--markers for cardiovascular and all cause mortality in heart failure. Eur J Heart Fail. 2011 Jun;13(6):626-32. Epub 2011 Mar 17. Teng LL, Shao L, Zhao YT, Yu X, Zhang DF, Zhang H. The beneficial effect of n-3 polyunsaturated fatty acids on doxorubicin-induced chronic heart failure in rats. J Int Med Res. 2010 May-Jun;38(3):940-8.

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