This is an article about Vitamin D deficiency and its role in heart disease by a leading cardiologist. Note the statistics on Vitamin D deficiency among Blacks and Hispanics, and that's because of their darker skin. She advises that one shouldn't take more than 4,000 IUs without a doctor's approval, but the Vitamin D Foundation, which is run by a doctor, recommends 5000 IUs daily for most people. However, this time of year (summer) if you get plenty of sun, as I do, you should cut back. What I do is take 5000 IUs of Vitamin D3 every day for most of the year, but in June, July, and August, I cut back to 5000 IUs every other day. Dr. Cinque
The author: Dr. Erin Michos, a preventive cardiologist and researcher at Johns Hopkins, has been studying the potential impact of vitamin D and cardiovascular health for over 10 years. Ironically, at her last annual checkup, Michos -- an avid outdoor runner -- was shocked to learn that she, too, was vitamin D deficient with a blood level of only 15 nanograms per milliliter. Should she take a vitamin D supplement for her heart health? In this piece, Michos and her internal medicine colleague Samuel Kim discuss the "sunshine" vitamin.
Vitamin D: Does it Even Matter?
Vitamin D is a hormone that helps control calcium levels in your body, which is ultimately important for your overall bone health. Vitamin D is produced in the skin from exposure to ultraviolet B rays in sunlight or taken in from food or dietary supplements. However, only limited food sources contain vitamin D, such as fatty fish, cod liver oil, eggs, milk, cereal and bread.
It's well-known that vitamin D is important for bone health. Very low levels of vitamin D can cause low levels of calcium in your blood, which can increase your risk of bone fractures, tingling and numbness sensation, and muscle weakness.
Recent research, including many of the studies that Michos conducted, has found that the sunshine vitamin may also be linked to other health conditions, like an increased risk of heart disease, stroke, diabetes, high blood pressure, abnormal cholesterol levels, erectile dysfunction and obesity.
Still, most of these observational studies do not prove a cause and effect because they don't involve intervention to correct low vitamin D levels. Having a low vitamin D level may simply be a risk marker indicating an individual is less healthy from other causes. Further research needs to be conducted to see if treating vitamin D deficiency through vitamin D supplementation can impact vascular disease outcomes. Fortunately, randomized clinical trials to answer this question are ongoing.
Who Becomes Vitamin D Deficient?
There are three major groups of people who develop vitamin D deficiency:
1. People who do not get enough vitamin D either through diet or sunlight exposure. Inadequate sunlight exposure is a problem for many people, especially darker-skinned individuals, those who use sunscreen for skin cancer protection and those who live in sun-limited areas in northern parts of the U.S.
2. Patients with kidney and liver diseases can have low vitamin D levels because they have decreased levels of important proteins that metabolize vitamin D.
3. Patients with bowel diseases, such as celiac disease, Crohn's disease and cystic fibrosis, or who have had any surgery that removes or reconnects the intestines or stomach cannot readily absorb vitamin D.
Who Should Get Tested?
In general, routine testing of vitamin D is currently not recommended except for people with kidney diseases, bowel diseases and a higher risk of osteoporosis, including previous bone fractures and low calcium levels.
When testing for vitamin D deficiency, physicians order the blood test for 25-hydroxyvitamin D concentration. This is the form of vitamin D that is the best measure of vitamin D stores in the body.
There is some controversy though about what is considered a normal amount of vitamin D in a blood test. The Institute of Medicine says that blood levels of 25-hydroxyvitamin D greater than 20 nanograms per milliliter should be adequate. However, many experts, including the Endocrine Society, advocate for levels greater than 30 nanograms per milliliter.
Because of the widespread use of sunscreen and more time spent indoors, particularly for occupational work, vitamin D deficiency is actually quite common. In the U.S. alone, the National Health and Nutrition Examination Survey found that over 40 percent of the American population was deficient in vitamin D (levels less than 20 nanograms per milliliter), with the highest rates seen in African-Americans (82 percent) and Hispanics (69 percent).
How Do You Treat Vitamin D Deficiency?
Vitamin D can be obtained from diet, but food sources generally have small quantities. In the absence of adequate sunlight exposure, it can be difficult to get enough vitamin D from diet alone. As a reference, 1 cup of milk (8 ounces) is roughly equal to about 100 International Units of vitamin D. For individuals with fair skin, 15 to 30 minutes of midday sun exposure during the summer months can give you close to 5,000 IU a day -- the equivalent of drinking 50 glasses of milk! Dark-skinned individuals and the elderly may produce less vitamin D in response to sunlight.
Prolonged peak sunlight exposure is not recommended for patients with a higher risk of skin cancer, especially individuals who are fair-skinned. Vitamin D from tanning beds is also not recommended given the high risk of skin cancer development.
In addition to diet and sunlight, you can get vitamin D from supplements. Vitamin D supplements come in either D2 (ergocalciferol) or D3 (cholecalciferol) forms. We generally recommend D3, since this is the form that is naturally produced in the body by sunlight, but either supplementation is reasonable. Most supplements at lower doses can be purchased over the counter without a prescription.
It is not completely clear what the ideal vitamin D intake goals should be for each individual. The U.S. Preventive Services Task Force recommends that all adults should intake at least 600 to 800 IU daily. The National Osteoporosis Foundation recommends somewhere between 800 to 1,000 IU daily for adults over age 50.
For patients with vitamin D deficiency, the guidelines recommend an initial treatment with a 50,000 IU vitamin D booster pill -- which normally requires a doctor's prescription -- once a week for eight weeks, then transitioning to a once-a-day supplementation between 1,500 and 2,000 IU. Patients on seizure medications, steroids, antifungals and HIV antiviral medications are often recommended to take two to three times more vitamin D because these medications can increase vitamin D metabolism. Personalized vitamin D treatments can be discussed with your doctor.
[See: The 12 Best Diets for Your Heart.]
What Are the Side Effects of Vitamin D Supplements?
In general, the side effects from vitamin D supplements are uncommon and relatively benign. However, high doses could lead to high calcium or phosphorous levels, increased thirst, a metallic taste in the mouth, tiredness, constipation and kidney stones. Although vitamin D toxicity is rare, it's not recommended to take more than 4,000 IU a day, unless a doctor is also monitoring your blood levels.
So What Does All This Mean for Me?
Vitamin D deficiency is common in the U.S., especially because many of us stay indoors and do not eat vitamin D-rich foods. There are reasonably good data to support the use of vitamin D supplementation by patients with a higher risk of osteoporosis. However, the benefit of supplementation in the normal aging population remains unclear.
Although there are more data to suggest that vitamin D deficiency may increase the risk of heart diseases, high blood pressure and obesity, it is not unclear at this time if and how vitamin D treatment will improve the development or progression of these diseases. More research is needed. Also, vitamin D treatment may only benefit those with deficiency, not individuals who already have adequate levels from sunlight and diet.
Back to our case about the author: Despite her physical activity levels, perhaps it isn't so surprising that Michos ended up vitamin D deficient. She eats a largely vegetarian/vegan diet, does most of her outdoor physical activity in the early morning, avidly uses sunscreen in the summer and lives in the northern part of the U.S. -- all known risk factors for deficiency.
In the end, Michos decided take a vitamin D supplement for her bone health, particularly because of her family history of osteoporosis. But at this time, despite her own research, she cannot recommend vitamin D for the sole purpose of preventing heart and related vascular diseases. As mentioned, there are several large randomized clinical trials ongoing now to test whether vitamin D treatment can reduce the risk of heart disease, cancer, diabetes and death. Hopefully, the results of these trials will inform future recommendations to patients.
Dr. Erin Michos is a cardiologist and associate professor of medicine at the Johns Hopkins University School of Medicine with a joint appointment in epidemiology at the Johns Hopkins Bloomberg School of Public Health. She is the associate director of preventive cardiology for the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease. Her research interests focus on general preventive cardiology, cardiovascular health in women, vitamin D and management of lipid disorders.
Medical error is the third leading cause of death in the United States, after heart disease and cancer, according to findings published this month in the British Medical Journal.
As such, medical errors should be a top priority for research and resources, say authors Martin Makary, MD, MPH, professor of surgery, and research fellow Michael Daniel, from Johns Hopkins University School of Medicine in Baltimore, Maryland.
But accurate, transparent information about errors is not captured on death certificates, which are the documents the Centers for Disease Control and Prevention (CDC) uses for ranking causes of death and setting health priorities. Death certificates depend on International Classification of Diseases (ICD) codes for cause of death, so causes such as human and system errors are not recorded on them.
And it's not just the US. According to the World Health Organization, 117 countries code their mortality statistics using the ICD system as the primary health status indicator.
The authors call for better reporting to help capture the scale of the problem and create strategies for reducing it.
Cancer and Heart Disease Get the Attention
"Top-ranked causes of death as reported by the CDC inform our country's research funding and public health priorities," Dr Makary said in an university press release. "Right now, cancer and heart disease get a ton of attention, but since medical errors don't appear on the list, the problem doesn't get the funding and attention it deserves."
He adds: "Incidence rates for deaths directly attributable to medical care gone awry haven't been recognized in any standardized method for collecting national statistics. The medical coding system was designed to maximize billing for physician services, not to collect national health statistics, as it is currently being used."
The researchers examined four studies that analyzed medical death rate data from 2000 to 2008. Then, using hospital admission rates from 2013, they extrapolated that, based on 35,416,020 hospitalizations, 251,454 deaths stemmed from a medical error.
That number of deaths translates to 9.5% of all deaths each year in the US — and puts medical error above the previous third-leading cause, respiratory disease.
In 2013, 611,105 people died of heart disease, 584,881 died of cancer, and 149,205 died of chronic respiratory disease, according to the CDC.
The new estimates are considerably higher than those in the 1999 Institute of Medicine report "To Err Is Human." However, the authors note that the data used for that report "is limited and outdated."
Strategies for Change
The authors suggest several changes, including making errors more visible so their effects can be understood. Often, discussions about prevention occur in limited and confidential forums, such as a department's morbidity and mortality conference.
Another is changing death certificates to include not just the cause of death, but an extra field asking whether a preventable complication stemming from the patient's care contributed to the death.
The authors also suggest that hospitals carry out a rapid and efficient independent investigation into deaths to determine whether error played a role. A root cause analysis approach would help while offering the protection of anonymity, they say.
Standardized data collection and reporting are also needed to build an accurate national picture of the problem.
Jim Rickert, MD, an orthopedist in Bedford, Indiana, and president of the Society for Patient Centered Orthopedics, told Medscape Medical News he was not surprised the errors came in at number 3 and that even those calculations don't tell the whole story.
"That doesn't even include doctors' offices and ambulatory care centers," he notes. "That's only inpatient hospitalization resulting in errors."
"I think most people underestimate the risk of error when they seek medical care," he said.
He agrees that adding a field to death certificates to indicate medical error is likely the way to get medical errors the attention they deserve.
"It's public pressure that brings about change. Hospitals have no incentive to publicize errors; neither do doctors or any other provider," he said.
However, such a major step as adding error information to death certificates is unlikely if not accompanied by tort reform, he said.
Still, this study helps emphasize the prevalence of errors, he said.
Human error is inevitable, the authors acknowledge, but "we can better measure the problem to design safer systems mitigating its frequency, visibility, and consequences."
They add that most errors aren't caused by bad doctors but by systemic failures and should 'not be addressed with punishment or legal action.
Dr. Cinque: So, what do they mean by "systemic" errors as opposed to doctor error? Do they mean that the doctor followed the standard protocol but the protocol was wrong? That's what it sounds like to me.
First, note that this has been reported before that medical errors are killing people on a grand scale. I mean: it has been known for decades. And they said then that steps were going to be taken, etc. etc. to reduce the medical carnage, but obviously, it hasn't worked. Second, medical deaths are still being grossly underreported. Take heart disease, for instance, the leading killer. If a person dies from the adverse effects of medications for heart disease, such as calcium channel blockers which are dangerous because they can trigger heart attacks, it's likely to be called a death from heart disease rather than heart disease treatment.
I'll admit that my perspective is very bleak. I think that most of medical treatment is killative. Leastways, most of it is harmful. Most of it amounts to suppressive, symptomatic, pharmaceutical tinkering which adds a new abnormality to the ones you've already got- complicating your condition, even if in some ways it seems better or looks better. They are not making you healthier; they are just making your disease manifest differently as you continue going downhill.
A good example are diuretics which are very widely prescribed but rarely do anybody any good. You're better off living with whatever fluid retention you have than trying to get rid of it forcibly that way. Better yet, take some constructive actions with diet, salt restriction, weight loss, exercise, supplements, and perhaps fasting to see if you can get it to resolve naturally and spontaneously through actual biological improvement rather than forcing measures. What's so terrible about that? Remember, patience is a virtue. You start doing the right things, and then you give it time. There is no need to resort to anything reckless and drastic.
This whole thing is complicated by the fact that there are areas in Medicine in which they do do valuable and beneficial things, such as surgery for cataracts, giving Metformin to Type II diabetics, antibiotics when necessary, and hormone replacement when indicated, especially when they are bio-identical. And I have no doubt that great work is being done with stem cells, and more is to come. But, none of that changes the fact that most of modern medical treatment is just disruptive pharmaceutical tinkering, which is hurting people and sometimes killing them. As a percentage, there isn't that much good in Medicine, and most of it should be avoided.
Does that seem radical? Well, I'm sorry, but it's true.
I am republishing here the April newsletter of Dr. Uffe Ravnskov. Dr. Ravnskov is a Swedish physician, a nephrologist (kidney specialist) and internist. And for many years, he has been at war with the medical establishment over cholesterol and use of cholesterol-lowering drugs, particularly statins. The evidence is very strong that statins do no prolong life, and they may even shorten life. I'm sure that Dr. Ravnskov would say that statins are the biggest medical scam of all time- and I agree with him. So, here is his latest newsletter. Be glad to know about this extremely knowledgeable and immensely competent physician, Dr. Uffe Ravsnkov.
In a recent Danish paper published in European Heart Journal the authors claimed, that negative statin-related news stories decrease statin persistence and increase myocardial infarction and cardiovascular mortality. It was based on the fact, that early statin discontinuation by some of more than 800,000 Danish statin-treated people was associated with the number of negative statin-related news stories published in the media between 1995 and 2010., and that 1.1% more of those with early statin discontinuation had died after 10 years of follow-up compared with those who continued.
A more reasonable explanation is that the statin-treated individuals learned that their many unpleasant symptoms were caused by the statins, because most adverse effects do not appear immediately. Very often they develop several weeks or months after the start of the treatment. As the side effects of almost all drugs appear immediately, neither the “patient” or the doctor realize that the late statin side effects are caused by the drug. The muscular problems, the mental disturbances and the decrease of sexual potency, the most common side effects, are therefore seen as a result of of increasing age.
An interesting observation is that the heart mortality difference of 1.1% is what those who continued their treatment won after 10 years of treatment. This is much less than reported from the statin trials. In the first statin trial 4S for instance, the difference between the statin and then placebo group as regards heart mortality was 2.5% after about five years of treatment. Notary impressive, but more than four times as much as in this paper.
Furthermore, there was not a word about total mortality in the paper. The only reason for excluding this information is of course, that either there was no difference, or that those, who stopped statin treatment lived longer than those who continued. It was not possible either for a Canada Free Press journalist to get this information from Børge Nordestgaard, one of the authors and head of the department, where the study was performed. He just answered the following: We probably could have looked at all-cause mortality. What I thought would have meaning for people that are interested in this field was myocardial infarction and cardiovascular death. Those are the two major endpoints that you look for when trying to prevent cardiovascular disease.
Aren´t the main interest of people on preventive medicine to prolong their life?
In an interview in the Danish newspaper Politiken, Nordestgaard declared that people, who stop their statin treatment have a 26% increased risk of a heart attack and 18% higher risk to die from a cardiovascular disease compared with those, who continue the treatment.
What explains his misleading words may be that he has strong economical links to the drug industry. In the section Conflicts of interest you can read the following: B.G.N. has received consultancy fees and/or lecture honoraries from Astra Zeneca, Pfizer, Merck, Amgen, Sanofi, Regeneron, Omthera, Dezima, ISIS Pharmaceuticals, Aegerion, Fresenius, B. Braun, Kaneka, Lilly, Kowa, and Denka Seiden.
Much evidence has shown that there is little benefit from statin treatment, if any at all. In my previous newsletter for instance, I told you about the Danish study, where the authors had calculated how may years you are able to prolong your life by statin treatment. What they found was that on average you can only prolong it by a few days.
Recently a research group from Italy, the UK and Sweden published a study in BMJ Open about the trends of statin use and heart mortality between 2000 and 2012 in 12 European countries. In all of the countries statin treatment has increased and heart mortality had decreased, apparently a support of statin treatment. However, there was no association between the degree of statin increase and the degree of mortality lowering between the countries. In Germany, for instance, statin treatment had increased by 54% during these years and heart mortality had decreased by 85%, whereas in Portugal statin treatment had increased by102%, whereas heart disease had decreased by only 41%.
As I have told you before, the directors of the statin trial do not allow access to the primary data. This has raised much criticism and a campaign, backed by the British Queen´s former doctor Sir Richard Thompson calling for urgent public enquiry into drugs firms' 'murky' practices. You can read more about that in in Daily Mail, in Sunday Express and in The Western Australia
In 2005 new, stricter regulations were introduced in the conduct and publication of randomized controlled trials. Since then the results of all statin trials have been minimal compared to those published before 2005 You can read more about that in a paper published in Expert Review of Clinical Pharmacology by Professor Harumi Okuyama and his co-authors; in a paper in Journal of Controversies in Biomechanical Research by Michel de Lorgeril and Mikael Rabaeus, and in Sunday Express. The authors of the two scientific journals are no amateurs; most of them are members of THINCS and de Lorgeril was the first who demonstrated the benefits of the Mediterranean diet.
Uffe Ravnskov, MD, PhD, independent investigator