[Fwd: Paradoxes and vitamin D]

[Guest guest]

Last month, Dr. Armin Zittermann, of Ruhr University in 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.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=16197570 & query_hl=31>

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 the paradigm to predict who will get heart disease. When

they 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

ten years later. It seems the equation is missing a few variables.

BMJ. 2003 Nov 29;327(7426):1267.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=14644971 & query_hl=30>

There are several interesting heart disease paradoxes. How well do you

know them? Good time for another quiz.

*1. The /French Paradox/ is the observation 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,

the most common explanation is that the French love red wine and the

antioxidants it contains. It was first described in 1987, before the

dermatologists scared the French out of their bikinis. The rates of

cardiovascular mortality in France are much lower in the South and West

than 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 ngs/ml in the sunnier

and drier South and West, but less than half that (17ngs/ml) in the

colder, rainier, and more polluted, North.

Arch Mal Coeur Vaiss. 1987 Apr;80 Spec No:17-21.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=3113393 & query_hl=24>

Hypertension. 2005 Oct;46(4):645-6. Epub 2005 Sep 12.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=16157787 & query_hl=4>

Hypertension. 2005 Oct;46(4):645-6. Epub 2005 Sep 12.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=16157787 & query_hl=2>

Osteoporos Int. 1997;7(5):439-43.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=9425501 & query_hl=3>

*2. The /Israeli Paradox/ is the observation that cardiovascular

disease is high in Israel despite a high consumption of polyunsaturated

omega-6 fats.*

**

A. True

B. False

True. According to the current paradigm, polyunsaturated fats contained

in vegetable seed oils are supposed to lower the risk of heart

disease. However, high consumption of these oils doesn?t appear to

prevent the Israelis from dying from heart attacks. Israel does,

despite its sunny weather, have a high incidence of vitamin D

deficiency. Average vitamin D levels among healthy adults in Lebanon,

right next door, are only 9.7 ngs/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.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=8960090 & query_hl=3>

Isr Med Assoc J. 2004 Feb;6(2):82-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=14986463 & query_hl=13>

J Bone Miner Res. 2000 Sep;15(9):1856-62.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=10977006 & query_hl=15>

Isr Med Assoc J. 2001 Jun;3(6):419-21.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=11433634 & query_hl=18>

J Steroid Biochem Mol Biol. 1992 Sep;42(8):855-61.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=1525046 & query_hl=9>

*3 The /Italian Paradox/ is the observation 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 olive trees and grapevines grow ?

in the sun. 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 ngs/ml in

the summer. Even average postmenopausal Italian women reached 36 ng/ml

in the summer. Anyone who has traveled in Italy, know 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.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=10873188 & query_hl=8>

Br J Nutr. 1999 Feb;81(2):133-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=10450331 & query_hl=5>

*4. The /Northern Ireland Paradox/ is the observation that a

population with a very high incidence of coronary heart disease does not

have high rates 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, its

altitude is 500 feet closer to the sun, and Toulouse only has 74 rainy

days per year. Lots more vitamin D in Toulouse!

QJM. 1995 Jul;88(7):469-77.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=7633873 & query_hl=14>

QJM. 1998 Oct;91(10):667-76.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=10024924 & query_hl=14>

Weatherbase, Belfast

<http://www.weatherbase.com/weather/weather.php3?s=042930 & refer=>

Weatherbase, Toulouse

<http://www.weatherbase.com/weather/weather.php3?s=116541>

*5. The /Indian Paradox/ is the observation that a high prevalence of

coronary artery disease in urban Indians is associated with /low/

saturated fat intake.*

**

A. True

B. False

True. Researchers found that a low saturated fat diet 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.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=9710843 & query_hl=16>

Arch Dis Child. 2002 Aug;87(2):111-3.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=12138058 & query_hl=21>

*6. The /Swedish Paradox/ is the observation that the strong

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.

Med J. 1991 Dec;36(6):165-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=1805375 & query_hl=121>

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. One theory - the theory that vitamin D

deficiency is a major cause of heart disease ? may explain these paradoxes.

*7. Scragg, Associate Professor in Epidemiology at the

University of Auckland, first proposed that vitamin D deficiency plays a

role in cardiovascular disease.*

**

A. True

B. False

True. For the last 25 years, Dr. Scragg has been trying to convince

anyone who would listen that vitamin D explains many of observations

about heart disease. These include the facts that heart disease is

higher at higher latitudes, lower altitudes, in the winter, in African

Americans, in older, inactive, and in more obese patients. Remember,

vitamin D blood levels are lower at higher latitudes, lower altitudes,

in the winter, in African Americans, in older, inactive, and in more

obese patients. Altitude is the least known of these associations. The

age adjusted mortality for heart disease in the USA 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.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=7327832 & query_hl=24>

J Chronic Dis. 1979;32(1-2):157-62.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=447776 & query_hl=8>

Sci Am. 1973 Sep;229(3):44-52.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=4731805 & query_hl=10>

*8. Dr. Scragg showed that higher vitamin D levels are associated with

lower risk for heart attack.*

**

A. True

B. False

True. In 1979, the Tromso Heart Study found corrected vitamin D levels

showed the same thing.

Int J Epidemiol. 1990 Sep;19(3):559-63.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=2262248 & query_hl=24>

Br Med J. 1979 Jul 21;2(6183):176.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=466339 & query_hl=51>

*9. Dr. Scragg is such a good scientist, he then published a study

which seemed to disprove his theory.*

**

A. True

B. False

True. 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 later. This seemed to disprove his theory, but he published

the data anyway, always a mark of a good scientist. We now know that

100,000 units are a small dose and that such ?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.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=7498100 & query_hl=24>

*10. Zittermann points out that vitamin D reduces vascular smooth

muscle proliferation, reduces vascular calcification, decreases

parathormone levels, reduces C reactive protein (CRP) and other markers

of inflammation, and decreases renin, all of which should prevent or

treat heart disease.*

**

A. True

B. False

True. He discusses most of the evidence that exists, tying heart

disease to vitamin D deficiency. A vitamin D theory of heart disease

explains the excess cardiovascular deaths at high latitude, low altitude

and during the winter. Furthermore, it explains the higher incidence of

heart disease in African Americans, older, inactive, and obese

individuals as these groups have significantly lower vitamin D blood levels.

Br J Nutr. 2005 Oct;94(4):483-92.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=16197570 & query_hl=31>

*11. In 2003, Zittermann discovered that patients with congestive heart

failure (CHF) have very low levels of vitamin D.*

**

A. True

B. False

True. Furthermore, he found that a 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.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=12570952 & query_hl=31>

*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.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=8935479 & query_hl=24>

J Epidemiol Community Health. 2005 Apr;59(4):274-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=15767379 & query_hl=26>

J Clin Epidemiol. 1988;41(7):679-89.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=3294350 & query_hl=125>

Chronobiol Int. 2001 May;18(3):541-57.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=11475422 & query_hl=34>

*13. Blood pressure is higher at higher latitudes, lower altitudes, in

the winter, in African Americans, in the aged, and in the obese.*

**

A. True

B. False

True. 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.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=9260973 & query_hl=55>

Ann Hum Biol. 2000 Jan-Feb;27(1):19-28.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=10673137 & query_hl=67>

Harv Health Lett. 2005 Sep;30(11):8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=16245402 & query_hl=75>

*14. Diabetes is more common at higher latitudes, at lower altitudes,

in African Americans, in the aged and the obese. Both blood sugar and

hemoglobin A1C are higher in the winter.*

**

A. True

B. False

True. Six final facts that can be explained with one theory: vitamin D.

Eur J Epidemiol. 1991 Jan;7(1):55-63.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=2026224 & query_hl=0>

Nutrition. 2001 Apr;17(4):305-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=11369169 & query_hl=0>

Diabetes Res Clin Pract. 2005 Aug;69(2):169-74. Epub 2005 Jan 12.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=16005366 & query_hl=108>

Diabetologia. 1982 Apr;22(4):250-3.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=6980156 & query_hl=44>

Am J Epidemiol. 2005 Mar 15;161(6):565-74.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=15746473 & query_hl=39>

*15. Two studies show vitamin D significantly reduces C reactive

protein (CRP), which may be a better predictor of heart disease than LDL

cholesterol. *

**

A. True

B. False

True. The Belgian study found a significant effect on CRP even though

their high-dose vitamin D group only got 500 units a day.

QJM. 2002 Dec;95(12):787-96.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=12454321 & query_hl=8>

J Clin Endocrinol Metab. 2003 Oct;88(10):4623-32.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=14557432 & query_hl=10>

*16. The risk for total mortality is significantly lower in subjects

with high vitamin D levels.*

**

A. True

B. False

True. However, the study 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.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=15955467 & query_hl=118>/

*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, or death rate

decreases.

We will have to wait years for science to find out if vitamin D prevents

and/or treats heart disease. While you are waiting, you have a choice.

You can wait vitamin D deficient (levels less than 40 ngs/ml) or you can

wait vitamin D sufficient (levels around 40-60 ngs/ml). The choice is

yours - another Pascal?s Wager

<http://www.cholecalciferol-council.com/pascal.pdf> - this time you are

betting your heart.

Also, while you wait for more studies, remember that vitamin D should be

obtained daily, not monthly or weekly. It should be obtained

physiologically, 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.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dopt=Abstr\

act & list_uids=15221979 & query_hl=27>

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.

If you live up north you can sun in the warmer months and use a sunlamp

<http://www.sperti.com/home.html> or take real vitamin D

(cholecalciferol) in the winter. Adults in the north could take one

5,000 unit capsule <http://www.bio-tech-pharm.com/products/d35.html> 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

<http://www.lef.org/newshop/items/item00251.html> 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 (25-hydroxy-vitamin D) around 50 ngs/ml,

year-around.

Last question: should patients dying from heart disease be allowed to

die vitamin D deficient? According to the current paradigm, the answer

is yes. At least, none of the cardiologists I know even bother to check

a vitamin D level. Given the scientific literature, that?s a bit

paradoxical.

Cannell, MD

The Vitamin D Council <http://www.cholecalciferol-council.com/>

9100 San Gregorio Road

Atascadero, CA 93422