Vitamin D Supplementation and Total Mortality

A Meta-analysis of Randomized Controlled Trials
Philippe Autier, MD; Sara Gandini, PhD
Arch Intern Med. 2007;167(16):1730-1737

Background Ecological and observational studies suggest that low vitamin D status could be associated with higher mortality from life-threatening conditions including cancer, cardiovascular disease, and diabetes mellitus that account for 60% to 70% of total mortality in high-income countries. We examined the risk of dying from any cause in subjects who participated in randomized trials testing the impact of vitamin D supplementation (ergocalciferol [vitamin D2] or cholecalciferol [vitamin D3]) on any health condition.

Methods The literature up to November 2006 was searched without language restriction using the following databases: PubMed, ISI Web of Science (Science Citation Index Expanded), EMBASE, and the Cochrane Library.

Results We identified 18 independent randomized controlled trials, including 57 311 participants. A total of 4777 deaths from any cause occurred during a trial size–adjusted mean of 5.7 years. Daily doses of vitamin D supplements varied from 300 to 2000 IU. The trial size–adjusted mean daily vitamin D dose was 528 IU. In 9 trials, there was a 1.4- to 5.2-fold difference in serum 25-hydroxyvitamin D between the intervention and control groups. The summary relative risk for mortality from any cause was 0.93 (95% confidence interval, 0.87-0.99). There was neither indication for heterogeneity nor indication for publication biases. The summary relative risk did not change according to the addition of calcium supplements in the intervention.

Conclusions Intake of ordinary doses of vitamin D supplements seems to be associated with decreases in total mortality rates. The relationship between baseline vitamin D status, dose of vitamin D supplements, and total mortality rates remains to be investigated. Population-based, placebo-controlled randomized trials with total mortality as the main end point should be organized for confirming these findings.

Author Affiliations: International Agency for Research on Cancer, Lyon, France (Dr Autier); and the European Institute of Oncology, Milano, Italy (Dr Gandini).

RELATED ARTICLE Can Vitamin D Reduce Total Mortality?
Edward Giovannucci
Arch Intern Med. 2007;167(16):1709-1710.

Self Control

"One can make a day of any size
and regulate the rising and setting of his own sun
and the brightness of its shining."

- John Muir

HeartMath 2008

Anti-inflammatory diets and IF Ratings

I was poking around nutritiondata.com today and discovered they include a box called an IF, or, Inflammation Factor Rating for foods. I found the concept and following explanation fascinating. The addition of this data along with a remarkable selection of nutrition facts makes this a very useful and user friendly website, worth reviewing as health and diet questions arise.

Among the many things they quantify for each food is its Nutrition Facts (just like the label on packaged foods); Glycemic Load, caloric ratio of carbs/fats/proteins, fullness factor, ratings for optimal weight loss or weight gain, nutrient balance and amino acid graphs, complete detailed nutrient breakdown of vitamins, minerals, fats, aminos, calories, carbs, fiber, and sterols.

There are lots of other useful tools on the site as well, so check it out! Today, I was curious about the nutritional value of rhubarb, a great early summer "vegetable" that cooks up so tasty in pies and compote. To maintain the low glycemic rating I sweetened it with agave syrup, and thickened it with arrowroot powder (no corn!). Be Well, Janis

The website includes the following "About" comments:
Nutrition Data's continuing goal is to provide the most accurate and comprehensive nutrition analysis available, and to make it accessible and understandable to all.

The information in Nutrition Data's database comes from the USDA's National Nutrient Database for Standard Reference and is supplemented by listings provided by restaurants and food manufacturers. The source for each individual food item is listed in the footnotes of that food's analysis page. In addition to food composition data, Nutrition Data also provides a variety of proprietary tools to analyze and interpret that data. These interpretations represent Nutrition Data's opinion and are based on calculations derived from Daily Reference Values (DRVs), Reference Daily Intakes (RDIs), published research, and recommendations of the FDA.

May 19, 2008 Lots of questions about anti-inflammatory diets and IF Ratings

If you've been following the health news for the past couple of years, you've probably tuned into the fact that many experts (including Andrew Weil, Barry Sears, Nicholas Perricone, Leo Galland, and yours truly) recommend an anti-inflammatory diet as a way to forestall aging and disease. For the benefit of those interested in this aspect of nutrition, Nutrition Data displays the IF (Inflammation Factor) Rating of foods and recipes as part of the detailed nutrition analysis.

Over the past few weeks, I've gotten a lot of questions about the IF Ratings of various foods. For example:

Q. Whole grains are supposed to be good for you and have an overall anti-inflammatory effect on the body, but your data on, e.g., barley and oats, indicates a high inflammatory effect. Could you please explain this?

Q. Why is the IF Rating for farmed salmon (-421) so much lower then the rating for wild salmon (+901). Both are salmon. Why there is such a big difference in the IF?

Q. I don't understand why walnuts have a negative IF Rating. I've heard that they are anti-inflammatory because they are high in omega-3 fats.

Q. Can you explain why an apple would be considered an inflammatory food?

First, a bit of background on how the IF Ratings (and I) came to be part of ND:

I developed the IF Rating system in 2005, as a way to estimate the inflammatory and anti-inflammatory potential of foods and combinations of foods. In 2006, I published The Inflammation Free Diet Plan, a book in which I detailed how the IF Rating system is calculated and how to use it. After the book and the IF Ratings were published, NutritionData.com (with my permission) added the IF Ratings to the site as part of its food and recipe analysis. Subsequently, I was invited to be a nutrition advisor for ND.

Even before I become a member of the ND team, I was delighted to make the IF Ratings available as part of NutritionData's analysis. However, one downside of making the ratings more widely available is that they now appear without the explanatory information included in the book. All of the above questions, for example, are addressed in The Inflammation Free Diet Plan.

Let me try to clear up a few of the most common misunderstandings:

Perhaps the most common misunderstanding is that all “healthy” foods are anti-inflammatory and all “unhealthy” foods are inflammatory. It’s a little more complex than that. The IF Rating system evaluates foods according to over 20 nutritional factors, including antioxidants, fatty acid composition, glycemic load, and many other nutrients. Often a food or meal will have a combination of pro- and anti-inflammatory factors of varying strengths, and the IF Rating is able to estimate the net effect of all these factors.

As you can see from the questions above, the IF Ratings often reveal some things that don’t line up with the conventional wisdom. Nonetheless, the ratings are based entirely on the actual nutritional composition of the foods and a little investigation always reveals an objective basis for “surprising” information.

The devil is in the (nutritional) details

In the case of whole grains, they do contain some anti-inflammatory nutrients, in particular zinc and folate. But they also contain a lot of carbohydrates, which tend to increase blood sugar, which tends to exacerbate inflammation. Likewise, the biggest contributor to the IF Rating of apples is the glycemic load, which, while not large, is still measurable. The net effect is a negative rating.

With salmon, it depends on what kind of salmon you’re talking about. Wild salmon is strongly anti-inflammatory, due in large part to its high levels of EPA and DHA, two strongly anti-inflammatory omega-3 fats. Farmed salmon, which is the majority of what is commercially sold, is also high in EPA and DHA. What most people don’t realize is that farmed salmon is also extremely high in arachidonic acid, which is the most inflammatory of the omega-6 fatty acids. This is because farmed salmon eat an artificial diet that is enriched with vegetable oils.

Not surprisingly, the difference in the diet makes a big difference in the nutritional composition of the fish. Like us, salmon are what they eat. So in farmed salmon, the anti-inflammatory benefits of the EPA and DHA are completely overwhelmed by the inflammatory capacity of the arachidonic acid. This is a critical distinction that is completely overlooked in most lists of “anti-inflammatory foods."

And finally, walnuts have a reputation for being anti-inflammatory because they are a good source of omega-3 fatty acids. While this is true, what people often overlook is that walnuts are even higher in omega-6 fatty acids. Research shows that a high ratio of omega-6 to omega-3 fats in the diet promotes inflammation. While eating walnuts increases your intake of omega-3 fats, it increases your intake of omega-6 fats even faster. Although walnuts can be a great part of a healthy, anti-inflammatory diet, eating walnuts alone will not improve the omega-6/omega-3 ratio of your diet.

Foods with negative IF Ratings are not necessarily bad for you!

As I explain in my book, the goal is not necessary to avoid all negatively-rated foods but to bring the diet into balance. Many foods with slightly negative IF Ratings, such as apples, walnuts, and whole grains, are quite healthful. In fact, it would be impossible to build a balanced diet without including foods that have negative IF Ratings.

Keep in mind that inflammation is a healthy and necessary part of the human immune response; so it makes sense that a healthy diet would include factors that support the inflammatory response. The problem is an excessive inflammatory response, driven by an excess of foods that promote inflammatory pathways.

While I believe it's wise to limit or avoid foods that are strongly inflammatory, such as french fries or farmed salmon, there's no reason to avoid wholesome foods like fruits and grains. Just aim to have the sum of all foods eaten in a day to have a positive IF Rating, so that the overall effect of the diet is anti-inflammatory.

I hope that clears up some of the confusion! You'll find answers to more frequently asked questions about the IF Rating system on my author's blog on Amazon.com as well as the book's website Inflammation Factor.com.

Posted by Monica Reinagel 1:35:20 PM

Vitamin D in the News

Presentations at the American Association of Clinical Endocrinologists, May 2008 highlight Vitamin D:

Vitamin D got considerable attention at the American Association of Clinical Endocrinologists “sunshine state” 2008 annual meeting. Presentations included one documenting hypocalcemia due to vitamin D deficiency in a patient adhering to a vegan diet, a second showing widespread underdiagnosis of vitamin D deficiency in patients with osteoporosis, and a third reporting high rates of continuing vitamin D deficiency in patients who have had a previous hip fracture.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Arch Intern Med -- Vitamin D as an Analgesic for Patients With Type 2 Diabetes and Neuropathic Pain, April 14, 2008, Lee and Chen 168 (7): 771

Jack Challem reports in his newsletter The Nutrition Reporter, June 2008, Vol19 No. 6:

paraphrased: (New South Wales, Aus)

51 patients with type 2 Diabetes & neuropathic pain entered into this study on diabetic neuropathy. All were Vitamin D deficient at the onset of the study. They were given vitamin D3 supplements, averaging 2,000 IU daily for 3 months. At the end of the study, perceived neuropathic pain decreased an avg. of 40-50% based on patient's feedback and responses to a pain questionnaire.

End-of-Life Discussions May Ease Dying

Patients Who Recall End-of-Life Discussions With Their Doctors More Likely to Die Comfortably
By Charlene Laino

June 4, 2008 (Chicago) -- Would you want to know if you only had six months to live?

It's a question no one really wants to face, but new research suggests that patients who recall having end-of-life conversations with their doctors may go more gently into the night.

"For patients who remember having such conversations, there are powerful positive effects," says researcher Alexi Wright, MD, a medical oncology fellow at the Dana-Farber Cancer Institute in Boston.

The findings were presented at the annual meeting of the American Society of Medical Oncology.

The study involved 332 cancer patients who eventually died; just over one-third recalled having end-of-life discussions with their doctors.

Wright says she cannot say with certainly what was actually discussed. "But since the patients who recalled these discussions had a significantly better understanding of their illness, I can surmise that the conversation included talking about their poor prognosis," she says.

Patients More Likely to Reap Hospice Benefits
Compared with patients who did not recall having end-of-life discussions with their doctors, those who did:

* Were 1.6 times more likely to enter a hospice in time to receive its benefits -- that is, to die as comfortable a death as possible. In the study, people who entered the hospice two months or more before death reported the best quality of life in their final weeks, Wright says.
* Were three times more likely to complete a do-not-resuscitate order and two times more likely to fill out a living will.
* Were no more likely to meet criteria for depression.
* Were no more likely to report being depressed, worried, anxious, or terrified when directly asked.

Patients who didn't recall talking to their doctor were more likely to be admitted to the ICU, to be placed on a ventilator, or to undergo resuscitation, Wright says.

People who received aggressive care generally reported worse quality of life, she tells WebMD.

"It's important for cancer patients with advanced cancer to talk to their doctors about the kind of care they want to receive," Wright says. "Your physical health can change suddenly, so have the discussion when you're still relatively healthy."

Taking to Your Doctor About End-of Life-Care
Barbara Murphy, MD, director of the pain and symptom management program at the Vanderbilt-Ingram Cancer Center in Nashville, Tenn., says patients with advanced cancer may sometimes need to take the initiative.

"Some doctors find it difficult to have discussions about a grave prognosis with their patients. But it's their job," she tells WebMD.

Murphy says it's important to know if you are terminally ill so that you can use the information in your decision-making.

"We don't know what patients want to do if they have six months to live. Some might want to go to Florida and visit their grandchildren, and others might want to be in a phase I study," Murphy says.

That said, there is a small percentage of patients who rather not know, "and react tearfully, angrily or even turn on the physician, as the messenger," she says.

SOURCES:
American Society of Clinical Oncology 44th Annual Meeting, Chicago, May 30-June 2, 2008.

Alexi Wright, MD, medical oncology fellow, Dana-Farber Cancer Institute, Boston.

Barbara Murphy, MD, director, pain and symptom management program, Vanderbilt-Ingram Cancer Center, Nashville, Tenn.

© 2008 WebMD, LLC. All rights reserved.

New Velvet
J. Davies 2008 all rights reserved

Older but Wiser? Brain Study reveals...

Older Brain Really May Be a Wiser Brain

By SARA REISTAD-LONG

When older people can no longer remember names at a cocktail party, they tend to think that their brainpower is declining. But a growing number of studies suggest that this assumption is often wrong.

Instead, the research finds, the aging brain is simply taking in more data and trying to sift through a clutter of information, often to its long-term benefit.

The studies are analyzed in a new edition of a neurology book, “Progress in Brain Research.”

Some brains do deteriorate with age. Alzheimer’s disease, for example, strikes 13 percent of Americans 65 and older. But for most aging adults, the authors say, much of what occurs is a gradually widening focus of attention that makes it more difficult to latch onto just one fact, like a name or a telephone number. Although that can be frustrating, it is often useful.

“It may be that distractibility is not, in fact, a bad thing,” said Shelley H. Carson, a psychology researcher at Harvard whose work was cited in the book. “It may increase the amount of information available to the conscious mind.”

For example, in studies where subjects are asked to read passages that are interrupted with unexpected words or phrases, adults 60 and older work much more slowly than college students. Although the students plow through the texts at a consistent speed regardless of what the out-of-place words mean, older people slow down even more when the words are related to the topic at hand. That indicates that they are not just stumbling over the extra information, but are taking it in and processing it.

When both groups were later asked questions for which the out-of-place words might be answers, the older adults responded much better than the students.

“For the young people, it’s as if the distraction never happened,” said an author of the review, Lynn Hasher, a professor of psychology at the University of Toronto and a senior scientist at the Rotman Research Institute. “But for older adults, because they’ve retained all this extra data, they’re now suddenly the better problem solvers. They can transfer the information they’ve soaked up from one situation to another.”

Such tendencies can yield big advantages in the real world, where it is not always clear what information is important, or will become important. A seemingly irrelevant point or suggestion in a memo can take on new meaning if the original plan changes. Or extra details that stole your attention, like others’ yawning and fidgeting, may help you assess the speaker’s real impact.

“A broad attention span may enable older adults to ultimately know more about a situation and the indirect message of what’s going on than their younger peers,” Dr. Hasher said. “We believe that this characteristic may play a significant role in why we think of older people as wiser.”

In a 2003 study at Harvard, Dr. Carson and other researchers tested students’ ability to tune out irrelevant information when exposed to a barrage of stimuli. The more creative the students were thought to be, determined by a questionnaire on past achievements, the more trouble they had ignoring the unwanted data. A reduced ability to filter and set priorities, the scientists concluded, could contribute to original thinking.

This phenomenon, Dr. Carson said, is often linked to a decreased activity in the prefrontal cortex. Studies have found that people who suffered an injury or disease that lowered activity in that region became more interested in creative pursuits.

Jacqui Smith, a professor of psychology and research professor at the Institute for Social Research at the University of Michigan, who was not involved in the current research, said there was a word for what results when the mind is able to assimilate data and put it in its proper place — wisdom.

“These findings are all very consistent with the context we’re building for what wisdom is,” she said. “If older people are taking in more information from a situation, and they’re then able to combine it with their comparatively greater store of general knowledge, they’re going to have a nice advantage.”

NY Times: May 20, 2008

Copyright 2008 The New York Times Company

Patience

"Have patience with all things, but chiefly have patience with yourself. Do not lose courage in considering you own imperfections, but instantly set about remedying them - every day begin the task anew."

-Saint Francis de Sales

Lifting Fog
J. Davies 2008 all rights reserved

Excessive Medical Testing Scrutinized

Inside Medicine: When playing it safe isn't better for you

By Dr. Michael Wilkes -
Published 12:00 am PDT Sunday, May 25, 2008

An appendectomy is usually a relatively simple and quick surgical procedure. For Paul, 42, a healthy commercial pilot, the operation was planned after a CT scan and blood tests suggested a high likelihood of infection. By the time the surgeon saw Paul, his doctor had already ordered the pre-op tests including blood coagulation studies, an EKG and a chest X-ray.

When the surgeon arrived, he examined Paul and looked at the CT scan. He also noticed that the doctor ordered hundreds of dollars worth of other tests. Most of the tests the doctor ordered – including the EKG, the coagulation studies and the chest X-ray – were unnecessary given Paul's excellent health. In an otherwise healthy 42-year-old, who has no prior history of heart or lung disease, the chance that an EKG or chest X-ray will detect anything serious is incredibly small – so small that the risk of radiation exposure and the cost of the tests have lead experts to recommend against the routine ordering of these tests before an operation.

When the surgeon saw Paul's doctor, he mentioned that most of the tests ordered were unnecessary. The doctor admitted that ordering the tests were long shots – in other words, very unlikely to provide any useful information and not likely to benefit the patient. But he explained that the tests might help the doctor if he was ever sued. The doctor admitted he didn't follow expert guidelines.

There are several reasons doctors don't follow guidelines. Sometimes they don't agree with the experts and feel their own experience is of greater value. Other times the patient doesn't really match the people in the research studies – the patient may be too old or have other illnesses that need to be factored into the clinical decision. Other times they choose not to do what the guidelines suggest.

In this case, however, the doctor rejected good scientific research based on his long-standing habits and a fear of a malpractice suit at some point in the future. His thinking went like this: Should the patient have a chest problem, an abnormal heart rhythm, or a problem with blood clotting, the tests would allow him to detect and manage the problem prior to surgery. While this is correct, let's say the chance of detecting one of these conditions (in a man with absolutely no history of illness or bleeding problems) is 1 in 10,000. This means that the doctor would order 9,999 chest X-rays on healthy middle-age men to detect one chest problem that might (in theory) make a difference during surgery. This is indeed a long shot.

At the very least, Paul should be asked whether he wants these low-yield, expensive tests. In my opinion, these tests should not have been considered for Paul. When a test has almost no benefit for the patient and all the benefit is to protect the doctor against a potential malpractice claim, we have a major "systems problem." The incentives for the doctor to do what is in the patient's best interest are out of alignment.

For Paul's doctor, no amount of discussion or review of the evidence was going to change his perceived need to order lots of tests. He was convinced that someday he would be sued and lots of tests would help his defense team. In fact, the opposite is true: Evidence suggests that doctors are more likely to be sued when they deviate from accepted expert guidelines. Still we spend at least $15 billion a year on unnecessary pre-operative tests that are ordered only as a protection against some theoretical, future lawsuit; they provide no benefit to the patient.

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Five Steps Closer to Calm

If it's hard for you to still your mind to meditate, the senior teachers at Kripalu Center have developed a five-step approach that could help. Follow these steps and allow yourself to fall into a deep meditative state that will reveal a closer connection to the present and help calm you when you're upset.

1. Breathe—Focusing on your breathing is an essential practice that draws your awareness inward and helps you experience the presence and flow of energy.
2. Relax—The more you relax, the more you deepen awareness of sensation.
3. Feel—Let your sense of feeling move beyond physical sensation. Acknowledge who you are as a being of energy.
4. Watch—Sense who you are as a witness; be a scientist observing phenomena arising in and around you.
5. Allow—Sense who you are with no preferences. Be present to the process of your life unfolding moment by moment.

Copyright © 2008 Cruz Bay Publishing, Inc,