Vitamin D: the Bad and the Ugly - UCSF CME vitDucsf.pdf · index, chronic kidney disease, hypertension, diabetes mellitus, smoking, use of vitamin D supplements) attenuated the association

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Vitamin D: The Good, the Bad and the Ugly

Clifford J Rosen MDMaine Medical Center Research [email protected]

Conflict of Interest Statement‐Corporate

• NO STOCKS or EQUITY

• Editor‐ UpToDate, New England Journal of Medicine, and Endocrine Reviews

• Laboratory Support: 

– Alexion Pharmaceuticals‐ Hypophopshatasia

• Speakers bureaus

– None

– no consulting fees

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Conflicts of Interest‐II

The views expressed in this talk represent my personal interpretation of the IOM report and not officially those of the committee or any 

member or staff associate

Outline

• The Vitamin D paradox

– Little evidence, widespread usage

• Vitamin D: Bone

– Evidence  for or against Vitamin D and Musculoskeletal health

• What about Vitamin D and cardiovascular health

• Vitamin D, Obesity and Diabetes

• Conclusion

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1927

2015 3.3 billion

©2011 MFMER  |  3081836‐6

Testing Vitamin D is Big Business: Vitamin D Monthly Test Volumes Endocrine Lab Rochester, 2004‐2010

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

Jan

04

Aug 0

4

Feb 0

5

Sep 0

5

Mar

06

Oct

06

Apr 0

7

Nov 0

7

Jun

08

Dec 0

8

Jul 0

9

Jan

10

Aug 1

0

25-hydroxy vitamin D

1,25-dihydroxy vitamin D

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The State of Vitamin D Testing and Interpretation

Prevalence of Vitamin D Levels from Commerical Lab Mayo’s Experience

0

30

60

90

Jul 0

6

Sep 0

6

Nov 0

6

Jan

07

Mar

07

May

07

Jul 0

7

Sep 0

7

Nov 0

7

Jan

08

Mar

08

May

08

Jul 0

8

Sep 0

8

Nov 0

8

Jan

09

Mar

09

May

09

Jul 0

9

Sep 0

9

Nov 0

9

Jan

10

Mar

10

May

10

Jul 1

0

Sep 1

0

Nov 1

0

Jan

11

Month

Pat

ient

s (%

)

25-80

10-24

<10>80

5 year pattern has changed very little

Is there truly a vitamin D epidemic?

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MAGICAL THINKING

Hollis et al 2013

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Hormones circulating bound to albumin or circulating in a free form (collectively known as Bioavailable Vitamin D) are more readily available to enter cells than hormones bound to their traditional binding proteins

Albumin

1. ‘Bioavailable’ D is consistent with other hormones

Vitamin D Binding Protein- Re-emerging

Does DBP concentration vary by ethnicity ?

*   Ethnic difference P<0.05

** No ethnic difference

Study Black White Assay

Schwartz et al, 2014 152 ± 107 (SD) mg/L 301 ± 210 (SD)* mg/L R&D

Powe et al, 2013 168 ± 3 (SE) 337 ± 5 (SE)* R&D

Denburg et al, 2013 100 240* R&D

Bhan et al, 2012 75 189* R&D

Powe et al, 2011 144 ± 102 (SE) 248 ± 122 (SE)*R&D

Winters et al, 2009 491 ± 128 (SD) 529 ± 202 (SD)** ALPCO

Bouillon et al, 1977 329 ± 54 (Zaire/Congo) 329 ± 43 (Belgium)** RID

Study Black White Assay

Schwartz et al, 2014 152 ± 107 (SD) mg/L 301 ± 210 (SD)* mg/L R&D

Powe et al, 2013 168 ± 3 (SE) 337 ± 5 (SE)* R&D

Denburg et al, 2013 100 240* R&D

Bhan et al, 2012 75 189* R&D

Powe et al, 2011 144 ± 102 (SE) 248 ± 122 (SE)*R&D

Study Black White Assay

Powe et al, 2013 168 ± 3 (SE) 337 ± 5 (SE)* R&D

African Americans

White Americans

Powe et al, 2013 NEJM

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VDBP assay comparisons

Nielson et al   2014

Summary

• Vitamin D circulates in the 25OHD form although 1,25OHD is also in the circulation and is the active compound

• 25OHD is bound to D binding protein (DBP) and albumin

• Dissociation of 25OHD from DBP may determine cellular action

• D binding protein assays are still being validated, but it is possible that there are no differences in DBP

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What Supports the Widespread Use of Vitamin D? 

• Evidence from clinical trials

• Observational data

• Expert opinion

• Case Reports

• Magical Thinking

IOM: Potential Indicators of Health Outcomes for Nutrient Adequacy for Calcium and Vitamin D

• Cancer/neoplasms

• Cardiovascular diseases and Hypertension

• T2D and metabolic Syndrome

• Falls

• Immune Response

• Neuropsychologic functioning

• Physical Performance

• Preeclampsia of pregnancy

• Skeletal Health‐only + evidence       

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So What is the evidence for Vitamin D and Fractures?

There are now almost 2 meta‐analyses published for every 1 RPCT of calcium/vitamin D and 

fracture risk

STEENBOCK 1920s

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Vitamin D and Calcium Reduces Fracture Risk (800IU+1200 mg/d)

Tang Lancet 2007

USPSTF: No Risk Reduction for Vitamin D and Hip Fracture- 2014

Vitamin D Does Not Increase BMD

Reid et al Lancet October, 2013

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A Closer Look at the Randomized Controlled Trials

PlaceboCa 1000mg+400 IU D

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Risk of Hip Fracture by Age Group in WHI: Age and Fall Interaction

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Chapuy et al NEJM 1992

• 1200 mg Ca + 800 IU Vitamin D

• Nursing home patients (n=1600)

• RPCT‐

• 33% reduction in hip fractures

800 IU per day Vitamin D

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Why Might Vitamin D Supplementation Protect Against 

Fractures in the Elderly?

Micro Archictectural Changes in the Skeleton with Low Vitamin D

SciTransl 2013

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Vit D deficiency results in osteomalacia

Cortical Porosity is increased in D Deficiency as is Haversian Canal Diameter and Osteocyte Lacunae Volume

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Osteomalacia and Cortical Porosity Are Associated with Micro Cracks and Propagation in Severe Vit D Deficiency

Vitamin D and the Cardiovascular System: Is there benefit?

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Biologic Plausibility for Vitamin D Actions on the Vascular System

• 1,25 OH D acts as a differentiation factor in SMC and endothelial cells

• 1,25 OH D induces a favorable cardioprotective gene response in SMC and endothelial cells

• VDR null mice, and 1 alpha hydroxylase null mice have a cardiomyopathy and high renin hypertension

• Vitamin D could limit the inflammatory response in mice (IL‐6, CRP, TNF)

• Vitamin D has been shown to improve vascular compliance

Observational Data from Large Cohorts• Framingham Offspring Study, participants who had a 25(OH)D <15 ng/mL 

(37.5 nmol/L) were more likely to have their first cardiovascular event during 5.4 years (mean) of observation than those with values ≥15 ng/mL (hazard ratio [HR] 1.62, 95% CI 1.11‐2.36) 

• In the National Health and Nutrition Examination Study (NHANES) 2001 to 2004, the prevalence of coronary heart disease (angina, myocardial infarction) was more common in adults with 25(OH)D levels <20 ng/mL compared with ≥30 ng/mL (odds ratio [OR] adjusted for age, race, and gender 1.49, 95% CI 1.17‐1.91)  Adjusting for other risk factors (body mass index, chronic kidney disease, hypertension, diabetes mellitus, smoking, use of vitamin D supplements) attenuated the association (OR 1.24, 95% CI 0.95‐1.62). 

• In NHANES The prevalence of heart failure and peripheral arterial diseases was also higher among those with 25(OH)D values <20 ng/mL (ORs 2.10 and 1.82, respectively) with similar attenuation after adjustment for other risk factors.

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“Observational studies identified for the current report found mixed associations between 25(OH)D and total cardio-vascular events, cardiovascular death, myocardial infarction, stroke, and fatal stroke.”

AHRQ Evidence Report, 2014

*Importantly: the WHI Study Failed to Show Cardiovascular ProtectionWith D and Calcium

CV outcomes risk stratified by vitamin D concentration for CV mortality

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Vitamin D,  Obesity, Type 2 DM

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So what’s wrong with taking more vitamin D?

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JAMA 2010 303 1815‐25

Dose was single annual dose of 500,000 IU (daily equivalent IF/365 = 1370 IU;

Sanders et al , 2010

High Dose Vitamin D increases serum levels of 25OHD levels in 75-125 nmol range

90 nmol/l

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0.5

1

1.5

2

2.5

3

0 10 20 30 40 50 60 70

Hazard Ratio

25OHD (ng/mL)

Mortality (All‐cause, Cancer, CVD)Michealsson et al, AJCN 2010

All cause

Cancer

CVD

Poly. (All cause  )

Poly. (Cancer  )

Poly. (CVD  )

The Uppsala Longitudinal Study of Adult Men, a community based cohort  (age at baseline: 71 y; n = 1194; 12.7 yr follow up)

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What should we be doing with vitamin D supplementation?

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Extended Oral Dosing of Vitamin D

10,000 IU D/d

5,000 IU D/d

1,000 IU/d

0 IU/d

*Heaney et al., AJCN 2003Heaney 2010

Simulated Dose‐Response of Total Dietary Vitamin D Intake and Achieved 25OHD at Latitudes >50⁰ During 

Winter

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Vitamin D upcoming trials

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Take Home Messages• Vitamin D is a hormone that promotes calcium absorption in the gut

• Impaired calcium absorption due to low vitamin D reduces mineralization and leads to changes in bone microstructure

• There is minimal RPCT data to support vitamin D supplementation to prevent any chronic disease‐except in the frail with OM 

• Basic studies of vitamin D are essential to fully understand its actions

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VDR null mice have increased energy expenditure