PracticeUpdate Cardiology Best of 2018

EDITOR’S PICKS 10

Supplemental Vitamins and Minerals for CVD Prevention and Treatment Journal of the American College of Cardiology Take-home message • In this meta-analysis, the authors evaluated the cardiovascular disease outcomes and all-cause mortality associated with supplemental vitamin and mineral intake. They report moderate- or low-quality evidence that folic acid and B-vitamin supple- mentation improves cardiovascular disease (CVD) or stroke outcomes. They noted no effect with multivitamin, vitamins C and D, β-carotene, calcium, and selenium supplementation. Finally, antioxidant combinations and niacin preparations were associated with increased risk of CVD or stroke. • The authors concluded that, since vitamin supplementation was not associated with a significant reduction in CVD risk, the risk-to-benefit ratio must be strongly considered.

COMMENT By David Rakel MD, FAAFP Meals vs Pills: Benefits of Vitamins and Supplements I t has been estimated that 52% of the population take nutritional supple- ments. But is this helpful compared with a healthy diet?

can deplete potassium, some commonly used medications are known to deplete nutrient levels and strategic replacement can be considered. Here is a list. Medication Nutrient depleted Metformin B12, folate, thiamine (B1) ACE inhibitors Zinc Acetaminophen Glutathione Proton pump inhibitors B-vitamins, calcium, magnesium,

vitamin A as a supplement bypasses this mechanism, causing harm when the body is exposed to too much vitamin A.

What this meta-analysis found Benefit

Why a meal is better than a pill The challenge of getting good nutrition through a pill vs a meal is that you can only pack so much into a capsule. This results in dilution of the amount of nutrients. The length of the ingredient list is inversely proportionate to the dose of each. You would be better off just eating a broccoli floret. Also, when we consume a nutrient in isolation, it is removed from the other chemicals that work synergistically in the plant. Studies suggest that the natural combination of chemicals found in nature is likely more powerful than taking what we think is the most important one in isola- tion. And, finally, when we take a vitamin, it bypasses the self-regulatory mechanisms of the body. For example, when one eats a carrot, the body obtains beta-caro- tene to make vitamin A. The body won’t make vitamin A unless it needs it. Taking

Abstract The authors identified individual randomized controlled trials from previous meta-analyses and additional searches, and then performed meta-analyses on cardiovascular disease out- comes and all-cause mortality. The authors assessed publications from 2012, both before and including the U.S. Preventive Service Task Force review. Their systematic reviews and meta-analyses showed generally moderate- or low-quality evidence for preventive benefits (folic acid for total cardiovascular disease, folic acid and B-vitamins for stroke), no effect (mul- tivitamins, vitamins C, D, β-carotene, calcium, Eating a healthy, plant-based meal is likely much more beneficial than getting nutri- tion through a pill. But, just as diuretics • Folic acid was associated with a 17% reduction in cardiovascular risk (risk reduction of 0.83) with a number needed to treat of 111. Using folic acid within a B-complex vitamin is being considered for stroke prevention. No benefit • Taking multivitamins, vitamin D, vitamin C, vitamin E, vitamin B6, magnesium, zinc, iron, and calcium had no effect on reducing cardiovascular risk. (overall risk reduction, 0.99). Potential for harm • Long-acting niacin (no flush) and mul- tivitamins were associated with an increase in all-cause mortality.

zinc, chromium, vitamin C, iron

Insulin Statins

Magnesium

Co-enzyme Q10

Dr. Rakel is Professor and Chair of the Department of Family & Community Medicine at the University of New Mexico School of Medicine in Albuquerque, New Mexico.

and selenium), or increased risk (antioxidant mixtures and niacin [with a statin] for all-cause mortality). Conclusive evidence for the benefit of any supplement across all dietary backgrounds (including deficiency and sufficiency) was not demonstrated; therefore, any benefits seen must be balanced against possible risks. Supplemental Vitamins and Minerals for CVD Prevention and Treatment. J Am Coll Cardiol 2018 Jun 05;71(22)2570-2584, DJA Jenkins, JD Spence, EL Giovannucci, et al. www.practiceupdate.com/c/69005

" …when we consume a

nutrient in isolation, it is removed from the other chemicals that work synergistically in the plant. "

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