I HAVE NO CONFLICTS OF INTEREST Page 1 Vitamins / supplements to be - - PDF document
Updates in Nutrition and Exercise: New Trials and New Guidelines for the Average Adult Jeffrey A. Tice, MD Professor of Medicine Division of General Internal Medicine University of California, San Francisco I HAVE NO CONFLICTS OF INTEREST
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Updates in Nutrition and Exercise:
New Trials and New Guidelines for the Average Adult
Jeffrey A. Tice, MD Professor of Medicine
Division of General Internal Medicine University of California, San Francisco
I HAVE NO CONFLICTS OF INTEREST
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Vitamins / supplements to be covered
– USPSTF, New trial
– CVD: New Trials and MA
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Audience Question #1
Vitamin Use in the U.S.A. “To improve or maintain overall health.”
– More than doubled since 1970s
are very popular with patients and are always in the news
Dickinson, JACN, 2014
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Why antioxidants?
that is associated with cancer, heart disease, and aging
that includes a variety of fruits and vegetables
higher intake / blood levels associated with less cancer, heart disease, and death
ß Carotene and Retinol Efficacy Trial (CARET)
–18,000 smokers –Ages 45 – 74
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CARET Randomized Trial Results
> 18,000 participants followed for 4+ years on beta-carotene or placebo
Omenn, NEJM, 1996
Vitamin E
reduction in CVD events up to daily intake > 200 IU per day
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The answer!
randomized trials of antioxidants
Bjelakovic, JAMA, 2007.
Death from any cause
16% increase
7% increase
4% increase
Trend towards increase (6%) All p << 0.05 except vitamin C Bottom line: actively discourage anti-oxidant use
Bjelakovic, JAMA, 2007.
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Folate, Homocysteine, and Heart Disease Homocysteine and Risk of Death
Homocysteine RR < 9 1.0 9-14.9 3.3 15-19.9 6.3 ≥ 20 9.9 p<0.001 Observational study!
Nygard, NEJM, 1997
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The Answer!
quality randomized trials
Clarke, Archives IM, 2010.
Folate / Homocysteine RCTs
25% decrease
No effect: 1.02 (.97-1.08)
No effect: 1.01 (.97-1.05)
No effect: 1.05 (.98-1.13) Folate does not prevent cancer or heart disease
Clarke, Archives IM, 2010.
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Folate And Neural Tube Defects (NTD)
– 4 mg of folate
– 0.4 mg of folate
– 46% reduction in NTD
Meta-analysis, Blencowe, IJE, 2010.
TO D OR NOT TO D...?
That is the question!
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Audience Question #2
Task Force updates recommend Vitamin D for:
Panel reviewed 1000 studies on 25 health outcomes to update previous 1997 recommendations
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Vitamin D: Adult Dietary Reference Intake* (U.S.)
600 IU / day
800 IU / day
*Institute of Medicine, 2010: Sufficient to meet the needs of virtually all people.
Vitamin D levels in Americans
Prevalence of inadequate 25(OH) vitamin D among American women ≥14 years old by IOM definitions
< 12 ng/ml 10 to 12% At risk of deficiency < 20 ng/ml 34 to 39% At risk of inadequacy < 30 ng/ml ~80%
NHANES 2003-2006
Why so little D?
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Vitamin D: The New Panacea
– Cancer (Colon, Breast, Prostate, Pancreatic, ...) – Cardiovascular disease – Multiple sclerosis, Type 1 DM, RA – Influenza and URIs – Chronic pain – Total Mortality!
RCT: VIDARIS Trial, JAMA, October 2012
25(OH) D URI incidence Vitamin D 48 ng/mL 3.7 infections/person Placebo 25 ng/mL 3.7 infections/person
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VITAL (VIT D and OmegA-3 TriaL)
Median 5.3 years (3.8-6.1)
– 67.1 years old – 51% female – 20% Black, 4% Hispanic, 71% NHW
Manson et al, NEJM, 2018
VITAL: Vitamin D Results
Outcome Hazard Ratio (95% CI) Cancer* 0.96 (0.88-1.06) Breast Cancer 1.02 (0.79-1.31) Death from Cancer 0.83 (0.67-1.02) Major CVD Event* 0.97 (0.85-1.12) Death from CVD 1.11 (0.88-1.40) Myocardial Infarction 0.96 (0.78-1.19) Death from Any Cause 0.99 (0.87-1.12)
* Co-Primary Endpoints ; 24 endpoints reported in Table 2
Manson et al, NEJM, 2018
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Vitamin D and Bone Strength
3 years
density, greater loss of bone
Burt et al, JAMA, 2019
US Preventive Services Task Force
– Vitamin D for fracture prevention (I) – Vitamin D for fall prevention (D)
I = Insufficient evidence: the balance of benefits and harms cannot be determined D = The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.
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IOM Report Calcium Recommendations
DRI – Adequate Intake Adolescents: 1300 mg/day Women and men (19-50 years): 1000 mg/day Women and men (>50 years): 1200 mg/day Current intake levels: Women: ~1/3 of their recommended intake Men: ~3/4 of their recommended intake Tolerable Upper Intake Level: 2500 mg/day
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Meta-analysis Annals IM 10/25/2016
associated with CVD in health adults
–Imperfect evidence –Diet is safer (fewer kidney stones) –Low fat dairy, tofu, canned fish with bones: 2-3 servings/day
Vitamin D and Calcium Take Home Points
prevention
– Ensure adequate calcium intake – Dietary calcium preferred
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OMEGA 3 FATTY ACIDS
A fishy story…
Omega-3 Fatty Acids
sources of Ω-3 fatty acids –EPA = eicosapentanoic acid –DHA = docosahexanoic acid
in EPA and DHA have fewer fatal and non fatal CV events
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Randomized trials of Ω-3s in heart disease
– Only positive trial
– Not even a trend towards benefit for post-MI, CVD or atrial fibrillation
– Harm: 3 extra days in ICU, trend - more death (p=0.054)
– No benefit
VITAL (VIT D and OmegA-3 TriaL)
Median 5.3 years (3.8-6.1)
– 67.1 years old – 51% female – 20% Black, 4% Hispanic, 71% NHW
Manson et al, NEJM, 2018
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VITAL: Omega-3 FA Results
Outcome Hazard Ratio (95% CI) Cancer* 1.03 (0.93-1.13) Breast Cancer 0.90 (0.70-1.16) Death from Cancer 0.97 (0.79-1.20) Major CVD Event* 0.92 (0.80-1.06) Death from CVD 0.96 (0.76-1.21) Myocardial Infarction 0.72 (0.59-0.90) Death from Any Cause 1.02 (0.90-1.15)
* Co-Primary Endpoints; 24 endpoints reported in Table 2
Manson et al, NEJM, 2018
REDUCE-IT
with LDL <100 and TG 135-499 mg/dL
Median 4.9 years
– 64 years old – 29% female – 90% White
Bhatt NEJM 2019
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REDUCE-IT
Bhatt NEJM 2019
New Meta-Analysis this month
Hu JAHA 2019
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Summary Omega-3 FA / Fish oil
in modern era of medical therapy for vascular disease
– 4 gm daily – Lowers TG – Appears to lower CVD event rates
General principles
unhelpful and may be harmful
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Summary
Discourage - harmful
Discourage - harmful
For child-bearing age to prevent neural tube defects
Older, frail patients to prevent fractures
Discourage – minimal 3 FA to no benefit
Michael Pollan’s Recommendations
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New Red Meat Systematic Reviews
participants
quality and found no significant differences
evidence
Johnston et al, Annals IM, 2019
SO WHAT ELSE CAN WE DO?
? Move
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Physical Activity and Health
2018 Physical Activity Guidelines Advisory Committee Scientific Report, 2nd Edition US Dept of Health and Human Services
Key Evidence Based Benefits (RCT) of Exercise
diabetes, cancer, CAD, dementia …
2018 Physical Activity Guidelines
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Impact of Limited Physical Activity
meeting the physical activity guideline) –$117 billion in annual health costs –10% of premature mortality
Carlson, Prev Chron Dis, 2018; Carlson, PCD, 2015.
Exercise Goals: Aerobic
intensity physical activity – Moderate intensity = brisk walking (3-4 mph, 100 steps/minute)
physical activity – Jog 5-6 mph for 60-120 minutes / week
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50% are at goal or above! Exercise Goals: Resistance
– Legs, hips, back, abdomen, chest, shoulders, arms
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Combined, fewer at goal, though improving Increasing Patient Exercise: MD
(YMCA, eHealth, elsewhere)
– ExerciseisMedicine.org Physician’s Action Guide
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Elements of an Exercise Prescription
your prescription
Short bursts count – it all adds up
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Technology
RCT Pedometers 12 weeks: 4 yr FU
Med, 6/25/19
nurse on behavior change
steps a day
minute
steps per day
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Summary
market
for real food
real food and exercise at home, work, and in the schools
A final take home point
enhance longevity / prevent disease based on observational evidence
benefits outweigh harms over the long term
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QUESTIONS?
Thank you!
MULTIVITAMINS
In the news
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MVI for Male MDs?
–14,641 male physicians ≥ 50 years followed for 11 years –RR 0.92, 95% CI 0.86 – 1.0, p=0.04 for the incidence of all cancers –4 interventions, 4+ outcomes, only this
–Can you say multiple comparisons?
COSMOS
– MVI, chocolate, and/or placebo – N = 20,000 – 5 year FU – Results in 2020
ClinicalTrials.gov: NCT02422745
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Tumeric / curcumin
skin health, lipids, heart disease, or cancer
Fish oil and cognitive function
cognitive issues, infants following supplementation during pregnancy, young children, and teens
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Co-Q 10
population and among statin users
CHF, HTN, chemotherapy side effects
AREDS for macular degeneration
degeneration
zinc
0.72 (0.52-0.98)
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If I Decide to Take a Supplement, How Can I Find a Quality Product?
Use Information from Independent Testing Laboratories
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Look for a “Seal of Approval” Learn As Much As You Can
http://ods.od.nih.gov
www.naturalstandard.com
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Exercise for Sleep
Yang JP 2012; Kredlow JBM 2015
Exercise for Cognitive Function
– 38% reduction in dementia
– Dose response for single episode – Dose response for duration of intervention over time
Sofi JIM 2011; Roig NeuroBioRev 2013.
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Exercise for Depression
–30+ minutes per day of activity reduced depression by 48%
– Significant improvement – Non-inferior to CBT or medication
Mammen AJPM 2013; Josefsson SJMSS 2014
Exercise for Anxiety
–Both aerobic and resistance exercise are effective –Non-inferior to CBT or medications
Bartley PNBP 2013; Gordon Sports Med 2017.
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Exercise for Quality of Life
–Consistent association with SF36
–Improvements in overall QOL and HRqol
Park ANR 2014; Bize; PrevMed 2007.
Exercise for Physical Function and Disease
endometrial, …)
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The final word
“Vitamins taken in excess of the dose required to prevent deficiency states have not improved
should recommend therapies to prevent disease in healthy patients only when randomized trials unequivocally demonstrate that net benefits
emphasize the importance of a nutritious diet, regular physical activity, and no smoking as the best ways to optimize health.”
Tice, JA. Archives IM, 2010.