Bisher AKIL, MD

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Mediterranean Diet Lowers Rates of Adverse Cardiovascular Events

In General Health, Heart on June 14, 2013 at 1:01 am

The so-called Mediterranean diet is thought, mostly on the basis of observational studies, to confer cardiovascular benefit. Now, Spanish researchers have put this diet to the ultimate test — a large, randomized, primary-prevention trial. About 7500 people (age range, 55–80) without known cardiovascular disease but with either diabetes or 3 non-diabetes cardiac risk factors were randomized to one of three diets:

  • Mediterranean diet supplemented with extra-virgin olive oil (at least 4 tablespoons daily)
  • Mediterranean diet supplemented with a daily 30-g serving of walnuts, almonds, and hazelnuts
  • Low-fat control diet

During average follow-up of 5 years, the primary composite outcome (myocardial infarction, stroke, or cardiovascular-related death) occurred significantly less often in the two Mediterranean-diet groups than in the control group (8 per 1000 person-years in each Mediterranean group vs. 11 per 1000 person-years in the control group). Among the three components of the primary endpoint, only stroke was significantly lower in the intervention groups. The two Mediterranean diets did not lower all-cause mortality significantly.

Summary appeared in Journal Watch General Medicine.

Comment: Few clarifications: 

1. Depending on group allocation, either a 15-liter (1 liter per week for 15 weeks) supply of extra-virgin olive oil (®Hojiblanca and ®Fundación Patrimonio Comunal Olivarero, both from Spain) or 3-month allowances of nuts consisting of 2 Kg (15 g per day) sachets of walnuts (®California Walnut Commission, Sacramento, CA), 1 Kg (7.5 g per day) sachets of almonds (®Borges SA, Reus, Spain), and 1 Kg (7.5 g per day) sachets of hazelnuts (®La Morella Nuts, Reus, Spain) were delivered to participants in the corresponding Mediterranean diet groups during each quarterly group session.

2.  In the Mediterranean diet with nuts group researchers offered participants three types of tree nuts, walnuts, hazelnuts and almonds. As stronger evidence supports that alpha-linolenic acid-rich walnuts might offer special advantages in cardiovascular prevention, researchers supplied a higher amount of walnuts than of almonds and hazelnuts.

3. The general guidelines to follow the Mediterranean diet that dietitians provided to participants included the following positive recommendations:

  1.  abundant use of olive oil for cooking and dressing dishes;
  2. consumption of ≥ 2 daily servings of vegetables (at least one of them as fresh vegetables in a salad), discounting side dishes;
  3. ≥ 2-3 daily servings of fresh fruits (including natural juices);
  4. ≥ 3 weekly servings of legumes;
  5. ≥ 3 weekly servings of fish or seafood (at least one serving of fatty fish);
  6. ≥ 1 weekly serving of nuts or seeds;
  7. select white meats (poultry without skin or rabbit) instead of red meats or processed meats (burgers, sausages);
  8. cook regularly (at least twice a week) with tomato, garlic and onion adding or not other aromatic herbs, and dress vegetables, pasta, rice and other dishes with tomato, garlic and onion adding or not aromatic herbs. This sauce is made by slowly simmering the minced ingredients with abundant olive oil.
  9. Negative recommendations are also given to eliminate or limit the consumption of cream, butter, margarine, cold meat, pate, duck, carbonated and/or sugared beverages, pastries, industrial bakery products (such as cakes, donuts, or cookies), industrial desserts (puddings, custard), French fries or potato chips, and out-of-home pre-cooked cakes and sweets.

4. The dietitians insisted that two main meals per day should be eaten (seated at a table, lasting more than 20 minutes).

5. For usual drinkers, the dietitian’s advice was to use wine as the main source of alcohol (maximum 300 ml, 1-3 glasses of wine per day). If wine intake was customary, a recommendation to drink a glass of wine per day (bigger for men, 150 ml, than for women, 100 ml) during meals was given.

6. Ad libitum consumption was allowed for the following food items: nuts (raw and unsalted), eggs, fish (recommended for daily intake), seafood, low-fat cheese, chocolate (only black chocolate, with more than 50% cocoa), and whole-grain cereals.

7. Limited consumption (1 serving per week) was advised for cured ham, red meat (after removing all visible fat), and cured or fatty cheeses.


CITATION:  Estruch R et al. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 2013 Feb 25.

Vitamin D and Calcium Supplementation in Women: Making Sense of Conflicting Data

In General Health on June 14, 2013 at 12:38 am

The following is a copy of a recent summary appeared in Journal Watch Women’s Health February 28, 2013:

NB: If you do not wish to read the entire post, just read the Conclusion section towards the end of the post _ BA

” Many clinicians (and patients) are confused about the benefits and risks of vitamin D and calcium supplementation for midlife and older women. We offer guidance on the appropriate use of these supplements.


Long recognized as important for skeletal health, vitamin D has garnered recent interest for its possible nonskeletal benefits. This vitamin is synthesized in the skin in response to sunlight and can also be ingested as vitamin D3 (cholecalciferol) or vitamin D2 (ergocalciferol). Natural dietary sources of vitamin D are few and include fatty fish and egg yolks. Vitamin D is also commonly added to milk and some other dairy products, cereals, and orange juice. Vitamin D is hydroxylated in the liver to 25-hydroxyvitamin D [25(OH)D], the major circulating metabolite, and is then further converted to 1,25-dihydroxyvitamin D (calcitriol).

A recent evidence-based Institute of Medicine (IOM) report1,2 provides guidelines about the amount of vitamin D that most North American women should consume. The IOM’s review confirmed that vitamin D clearly confers bone benefits, but found that current data are insufficient to conclude that it lowers risk for nonskeletal diseases (e.g., cardiovascular disease [CVD], diabetes, cancer); thus, the IOM based its recommendations only on the amount required for bone health:

  • 600 international units (IU) daily for women aged 70 and 800 IU daily for those aged >70 will meet the vitamin D needs of at least 97.5% of U.S. and Canadian women.
  • These recommended dietary allowances (RDAs) correspond to a 25(OH)D serum level of 20 ng/mL.
  • 25(OH)D assessments are not necessary for most women who meet the RDA guidelines.

Because the IOM assumed little to no sun exposure, these guidelines apply even to individuals living in northern latitudes during the winter.

The IOM also reviewed safety data on high-dose vitamin D supplements and set the tolerable upper level of daily intake at 4000 IU (previously 2000 IU). Extremely high intakes can lead to hypercalcemia, thereby damaging the kidneys and heart, but data are lacking about the long-term safety of intakes above the RDA. Several ongoing randomized trials should clarify the benefit-risk balance of such doses. For example, in the large, 5-year VITamin D and OmegA-3 TriaL (VITAL), researchers are testing 2000-IU daily supplemental vitamin D3 for primary prevention of cancer and CVD.3

The IOM’s recommendations reflect a population-level, public-health orientation and are intended to complement but not replace individualized clinical decision making. Clinical guidelines that combine both perspectives are useful.4 Per the IOM, most healthy individuals should do their best to meet the aforementioned RDAs and do not need routine 25(OH)D testing. However, for individuals with risk factors for, or clinical conditions associated with, vitamin D insufficiency (e.g., malabsorption, osteoporosis), 25(OH)D measurement is prudent. If the level is <20 ng/mL, two approaches to vitamin D therapy are as follows:

  • Administer 50,000 IU of vitamin D2 once weekly for 8 weeks, followed by a daily maintenance dose of vitamin D (typically 800–1000 IU) to maintain the target 25(OH)D level.
  • Start directly with daily vitamin D3 supplementation (dose determined by extent of insufficiency).

Roughly speaking, 25(OH)D increases by 6 to 10 ng/mL for each additional 1000 IU daily of supplemental vitamin D3.4 Reassessing 25(OH)D is necessary about 3 months after a dose change to check that the target level has been attained. Some organizations recommend maintenance levels >30 ng/mL for “at-risk” individuals. The IOM recommends avoiding 25(OH)D levels >50 ng/mL, as some research suggests excess risk for CVD,1 pancreatic cancer,5 all-cause mortality,6 and even fractures7 at these levels.


The IOM also conducted a parallel assessment of calcium and concluded that this nutrient provides critical bone benefits.1,2 The Women’s Health Initiative (WHI), a randomized trial of the benefits and risks of daily calcium (1000 mg) and low-dose vitamin D (400 IU) supplements in 36,282 postmenopausal women (age range, 50–79), showed that treatment led to significantly less bone loss at the hip and a 12% reduction in hip fracture rate.8 Although the latter figure was lower than expected and not statistically significant, it was one of the findings that led to the influential U.S. Preventive Services Task Force’s 2013 assertion that this treatment is ineffective for fracture prevention at midlife and beyond.9 However, among WHI participants aged 60 — the age group most likely to sustain osteoporotic fractures — the intervention was associated with a larger, statistically significant 21% reduction in hip fracture rate.8 Moreover, among participants who took their study pills regularly and were not already taking supplements, the intervention was associated with a still larger, statistically significant 30% reduction in hip fracture rate.8 Participants with intakes 1200 mg/daily at baseline did not clearly benefit from the intervention, suggesting that “more is not necessarily better.” The evidence as a whole points to the need for sufficient calcium to ensure bone health and prevent fractures.1,2,10

The IOM set the current RDA for calcium (from food plus supplements) at 1000 mg for women aged 50 and 1200 mg for those aged >50. Many women are consuming unnecessarily high doses of supplemental calcium. Instead, they should aim to meet the RDA by eating calcium-rich foods (e.g., milk, yogurt, cheese, and other dairy foods; fish such as sardines or salmon; tofu; calcium-fortified juice and cereals; broccoli, collard greens, and kale) and consider supplements only if their diet does not provide the recommended amount of calcium. Given that the median daily dietary calcium intake of midlife and older women is about 700 mg1 (equivalent to 2–3 servings of the above foods), many women need no more than about 500 mg daily in calcium supplements to meet the RDA.10

Calcium from food does not seem to raise CVD risk (indeed, observational data suggest that the opposite may be true11), but calcium supplements may raise blood calcium levels more rapidly than dietary calcium, thereby boosting risk for heart disease. This hypothesis, however, remains unproven.10 In the WHI, no overall elevation in myocardial infarction (MI) or stroke risk occurred,12 although a 22% increase in MI risk was noted among participants who first began taking calcium supplements as part of the trial (but not among those already taking them at baseline).13 However, the supplements did not increase coronary artery calcification at trial’s end.14 Also, a review of randomized trials showed that, compared with placebo, calcium supplements (whether alone or with vitamin D) were not linked to CVD risk.11 Nevertheless, striving to obtain calcium from food rather than from supplements — while ensuring adequate concurrent vitamin D intake — is wise.

Regarding other clinical outcomes in the WHI, a significant 17% increase in risk for kidney stones was noted,8 but the background intake of calcium was high. Total mortality was reduced by 9% (a finding of borderline statistical significance),15 and risk for total, colorectal, or breast cancer was unaffected.16 Overall, the findings suggest that calcium supplementation to bring the total intake of this nutrient to the RDA level — but not to exceed it — can lower risk for hip fracture without raising risk for CVD or other major adverse events.10


To maintain bone health, current recommendations for daily vitamin D intake call for 600 IU for women aged 70 and 800 IU for those aged >70, and recommendations for daily calcium intake are 1000 mg for women aged 50 and 1200 mg for those aged >50. The benefit–risk balance of long-term supplementation with doses of vitamin D and/or calcium that exceed the RDA is the subject of ongoing research. Most women should endeavor to eat a diet rich in these nutrients and consider supplements only if necessary to meet the RDA.

— JoAnn E. Manson, MD, DrPH, and Shari S. Bassuk, ScD

Dr. Manson is Professor of Medicine and Chief, Division of Preventive Medicine, Harvard Medical School and Brigham and Women’s Hospital; and a WHI principal investigator. Dr. Bassuk is an epidemiologist and science writer at Brigham and Women’s Hospital.


1. Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. The National Academies Press; 2011.

2. Ross AC et al. The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: What clinicians need to know. J Clin Endocrinol Metab 2011 Jan; 96:53.

3. Manson JE et al. The VITamin D and OmegA-3 TriaL (VITAL): Rationale and design of a large randomized controlled trial of vitamin D and marine omega-3 fatty acid supplements for the primary prevention of cancer and cardiovascular disease. Contemp Clin Trials 2012 Jan; 33:159.

4. Szmuilowicz ED and Manson JE. How much vitamin D should you recommend to your nonpregnant patients? OBG Management 2011 Jul; 23:45.

5. Stolzenberg-Solomon RZ et al. Serum vitamin D and risk of pancreatic cancer in the Prostate, Lung, Colorectal, and Ovarian Screening Trial. Cancer Res 2009 Feb 15; 69:1439.

6. Melamed ML et al. 25-hydroxyvitamin D levels and the risk of mortality in the general population. Arch Intern Med 2008 Aug 11; 168:1629.

7. Sanders KM et al. Annual high-dose oral vitamin D and falls and fractures in older women: A randomized controlled trial. JAMA 2010 May 12; 303:1815.

8. Jackson RD et al. Calcium plus vitamin D supplementation and the risk of fractures. N Engl J Med 2006 Feb 16; 354:669.

9. U.S. Preventive Services Task Force. Vitamin D and Calcium Supplementation to Prevent Fractures in Adults: U.S. Preventive Services Task Force Recommendation Statement.

10. Manson JE and Bassuk SS. Calcium supplements: Do they help or harm? North American Menopause Society (NAMS) Practice Pearl September 6 , 2012.

11. Wang L et al. Calcium intake and risk of cardiovascular disease: A review of prospective studies and randomized clinical trials. Am J Cardiovasc Drugs 2012 Apr 1; 12:105.

12. Hsia J et al. Calcium/vitamin D supplementation and cardiovascular events. Circulation 2007 Feb 20; 115:846.

13. Bolland MJ et al. Calcium supplements with or without vitamin D and risk of cardiovascular events: Reanalysis of the Women’s Health Initiative limited access dataset and meta-analysis. BMJ 2011 Apr 19; 342:d2040.

14. Manson JE et al. Calcium/vitamin D supplementation and coronary artery calcification in the Women’s Health Initiative. Menopause 2010 Jul; 17:683.

15. LaCroix AZ et al. Calcium plus vitamin D supplementation and mortality in postmenopausal women: The Women’s Health Initiative calcium-vitamin D randomized controlled trial. J Gerontol A Biol Sci Med Sci 2009 May; 64:559.

16. Manson JE et al. Vitamin D and prevention of cancer — ready for prime time? N Engl J Med 2011 Apr 14; 364:1385.



High Calcium Intake Is Associated with Earlier Mortality in Women

In General Health on June 14, 2013 at 12:28 am

Previous studies have reported that oral calcium supplementation is associated with elevated risk for adverse cardiovascular (CV) events such as myocardial infarction  Moreover, in a recent study  high-dose calcium supplementation was associated with excess CV-related mortality in men. In this prospective cohort study, Swedish investigators assessed the associations between long-term calcium intake and all-cause and CV-related death in 61,000 women born between 1914 and 1948. Researchers estimated dietary, supplemental, and total calcium intake from food-frequency questionnaires that were completed at baseline (1987–1990) and in 1997. Median follow-up was 19 years. Compared with dietary calcium intakes of 600 to 999 mg daily, daily intakes of 1400 mg were associated with significantly higher rates of death from all causes (multivariate adjusted hazard ratio, 1.4), CV disease (AHR, 1.5), and ischemic heart disease (AHR, 2.1), but not from stroke. Similar results were obtained for total calcium intake. Vitamin D intake did not modify the associations.

Published in Journal Watch General Medicine

Comment: This is a case of too much of a good thing; the study suggests that people avoid excessive calcium intake (i.e., 1400 mg daily) and that high calcium intake should be reserved for situations in which benefits clearly outweigh risks. For more information about Calcium and Vitamin D please see the post titled: “Vitamin D and Calcium Supplementation in Women: Making Sense of Conflicting Data” on this blog. _BA

CITATION Michaëlsson K et al. Long term calcium intake and rates of all cause and cardiovascular mortality: Community based prospective longitudinal cohort study. BMJ 2013 Feb 13; 346:f228. (


In General Health on June 14, 2013 at 12:12 am

Gastroesophageal reflux disease (GERD) is a chronic digestive disease that occurs when stomach acid or, occasionally, bile flows back (refluxes) into your food pipe (esophagus). The backwash of acid irritates the lining of your esophagus and causes GERD signs and symptoms. Signs and symptoms of GERD include acid reflux and heartburn. Both are common digestive conditions that many people experience from time to time. When these signs and symptoms occur at least twice each week or interfere with your daily life, doctors call this GERD.

Mechanism: When one swallows, the lower esophageal sphincter — a circular band of muscle around the bottom part of your esophagus — relaxes to allow food and liquid to flow down into the stomach. Then it closes again. However, if this valve relaxes abnormally or weakens, stomach acid can flow back up into the esophagus, causing frequent heartburn. This constant backwash of acid can irritate the lining of the esophagus, causing it to become inflamed (esophagitis). Over time, the inflammation can erode the esophagus, causing complications such as bleeding or breathing problems. (from Mayo Clinic webpage -edited)New guidelines on the diagnosis and management of gastroesophageal reflux disease appear in the American Journal of Gastroenterology. Among the strong recommendations with the highest level of evidence:

  • Physicians should not use barium radiographs to diagnose the condition.
  • Use an 8-week course of proton-pump inhibitors (PPIs) for symptom relief and healing of erosive esophagitis.
  • The various PPIs show the same level of efficacy. (Nexium is like Prevacid, Prilosec,…etc)
  • There is not an increased risk for adverse cardiovascular events among PPI users taking Plavix (clopidogrel).


Comments: GERD is a common complaint among all patients; insurance companies have always tried to push subscribers to use over the counter medications instead of prescription drugs, for financial reasons. These guidelines support the use of any PPI! BA

Reference:  American Journal of Gastroenterology article (Free PDF)