Multivitamin use and the risk of myocardial infarction: a population-based cohort of Swedish women

A beneficial cardiometabolic health profile associated with dietary supplement use: A cross-sectional study

As a follow-up to an earlier study demonstrating healthier cardiometabolic profiles among long-term multiple dietary supplement (LTMDS) users, we examined if cardiometabolic health benefits associated with LTMDS use persisted with aging. The study is based on LTMDS users from North America and 2007-2010 NHANES participants who were used for comparison to the LTMDS users. NHANES subjects were classified as non-dietary supplement (NS) users, single supplement/single purpose supplement (SS) users, multivitamin/mineral supplement (MVMS) users, and multiple dietary supplement (MDS) users. Supplement groups were compared for total, HDL and LDL cholesterol; triglycerides; glucose; insulin; CRP and HbA1c ≥ 6.5%, adjusting for age, sex, income, education, BMI, history of CVD, and medications for hypercholesterolemia and diabetes. Geometric mean (95% confidence interval) LDL cholesterol was significantly lower (P < 0.05) for all supplement groups (SS: 110 (104-117) mg/dL; MVMS: 113 (107-119) mg/dL; MDS: 115 (111-118) mg/dL; LTMDS: 112 (105, 119) mg/dL) compared with the NS users (122 (118-126) mg/dL). Compared with the NS group, MDS users had significantly (P < 0.05) lower mean total cholesterol (198 (194-201) vs 201 (197, 206) mg/dL), MDS and LTMDS users higher mean HDL cholesterol (54.2 (53.3-55.1) and 60.0 (57.4, 62.7) mg/dL vs 52.0 (50.8-53.3) mg/dL), LTMDS users lower fasting glucose (100 (98-103) vs 105 (103-106) mg/dL), SS and MDS users lower insulin (8.4 (7.4-9.6) and 9.1 (8.3-9.9) vs 10.2 (9.4-11.1) μIU/mL), and MDS users lower CRP (% ≥ 1.5 mg/L, 50.8 (47.9-53.6) vs 57.0 (52.4-61.6) %). These findings add to the evidence that use of dietary supplements may provide cardiometabolic health benefits.

Optimal Nutrition in the Older Adult: Beneficial Versus Ineffective Supplements

PURPOSE OF REVIEW

Proper nutrition in older adults is essential, as nutritional deficiencies are common in this population. This review aims to summarize the benefits and risks of nutritional supplementation in the older adult population including the efficacy of various supplements, their risks, and common drug interactions with frequently prescribed medications.

RECENT FINDINGS

In recent years, a growing percentage of older adults have been found to take multiple daily nutritional supplements. This population has complex nutritional needs due to the physiology of aging and the presence of comorbidities. However, many primary care providers are unaware of the benefits and drawbacks of nutritional supplementation in the elderly. This review summarizes the current literature to provide more clarity to providers on how to support this population's nutritional needs. Nutritional supplementation is essential for elderly populations who may not be able to obtain adequate nutrition from dietary sources. Supplements vary widely in efficacy and safety. As such, supplementation should be individualized and guided by a qualified healthcare provider to ensure patients receive effective, beneficial nutrition.

Multivitamin/mineral supplementation and the risk of cardiovascular disease: a large prospective study using UK Biobank data

PURPOSE

Despite the widespread use of multivitamin/mineral supplements, the effects of multivitamin/mineral on cardiovascular disease (CVD) remain inconclusive. We aimed to prospectively investigate how multivitamin/mineral use is associated with CVD.

METHODS

This population-based cohort study included 465,278 men and women who participated in the UK Biobank and were free from CVD at baseline. Participants were enrolled between 2006 and 2010 and followed-up until the end of 2018. Data on supplement use including multivitamin/mineral were collected using self-reported questionnaires. Cox proportional hazards models were used to estimate the hazard ratios of CVD events in relation to multivitamin/mineral use.

RESULTS

During the follow-up, we identified 25,772 cases of CVD events, 4754 cases of CVD mortality, 18,728 cases of coronary heart disease, 6726 cases of myocardial infarction, and 4561 cases of stroke. The multivariable-adjusted hazard ratios associated with multivitamin/mineral use were 0.96 (95% CI: 0.93, 0.99) for CVD events, 0.92 (0.86, 1.00) for CVD mortality, 0.96 (0.93, 0.99) for coronary heart disease, and 0.92 (0.86, 0.97) for myocardial infarction. Subgroup analysis suggested that multivitamin/mineral use was associated with a significantly lower risk of CVD events in participants aged < 60 years and in former and current smokers (P for interaction ≤ 0.01). Sensitivity analyses showed no substantial change in the results when we excluded participants who developed CVD events during the first 2 years of follow-up.

CONCLUSION

Multivitamin/mineral supplementation was associated with very modest reductions in CVD events. Age and smoking might modify these associations.

Serum 25-hydroxyvitamin D is associated with fracture risk only during periods of seasonally high levels in women with a high body mass index

Serum 25-hydroxyvitamin D (S-25OHD) is used to assess vitamin D status and is known to be affected by season and fat mass. Because these factors are often ignored when interpreting S-25OHD, assessment of vitamin D associations with disease outcomes may be distorted. We aimed to investigate the impact of season of blood draw and fat mass on the association of S25OHD with fracture risk. We enrolled 5000 women, mean ± SD age 68 ± 7 years, with dual-energy x-ray absorptiometry (DXA) scans and blood collection in a population-based cohort. Proportional hazards regression, stratified by season and fat mass, was used to determine hazard ratios (HRs) of fracture according to categories of S-25OHD. Our secondary exposures were serum 1,25-dihydroxycholecalciferol (1,25-(OH)₂ D₃ ), the most active vitamin D metabolite and plasma parathyroid hormone (P-PTH). During an average of 9.2 years of follow-up, 1080 women had a fracture. Women with S-25OHD <30 nmol/L drawn during sunny months (May-October) had a multivariable-adjusted fracture HR of 2.06 (95% CI, 1.27-3.35) compared with those with S-25OHD >60 nmol/L; those with S-25OHD 30-40 nmol/L had an HR of 1.59 (95% CI, 1.12-2.26). In contrast, S-25OHD drawn during November through April was unrelated to fracture risk. The increased risk with low sunny season S-25OHD was seen only among women with body mass index (BMI) ≥25 kg/m² or fat mass index (FMI) ≥9.8 kg/m² . High fat mass and low S-25OHD were independently related to lower S-1,25-dihydroxycholecalciferol, which itself predicted fracture risk with samples collected during the sunny season. Irrespective of season, P-PTH was unrelated to fracture risk. We conclude that S-25OHD is associated with fracture risk only if drawn during periods of seasonally high levels in women with a high BMI. These results have implications for the evaluation of vitamin D status and can explain the lack of effect seen with vitamin D supplementation in many fracture trials. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

1,25-Vitamin D3 protects against cooking oil fumes-derived PM2.5-induced cell damage through its anti-inflammatory effects in cardiomyocytes

The functional role of 1,25-vitamin D3 in cooking oil fumes (COFs)-derived PM2.5-induced cell damage is largely unexplored. The present study investigated the protective role of 1,25-vitamin D3 against cell injury by possible involvement of JAK/STAT and NF-κB signaling pathways in cardiomyocytes. Cell viability was measured using CCK-8 assay, and cell apoptosis was analyzed by flow cytometry, qRT-PCR and Western blot in cultured rat neonatal cardiomyocytes treated with 1,25-vitamin D3 and COFs-derived PM2.5. Expressions of JAK/STAT and NF-κB signaling pathway were measured by Western blot. The results suggested that treatment with COFs-derived PM2.5 significantly decreased cell viability and increased apoptosis and oxidative stress in cultured rat neonatal cardiomyocytes. 1,25-vitamin D3 pretreatment alleviated the cell injury by increasing cell viability and decreasing apoptosis in the cardiomyocytes. 1,25-vitamin D3 pretreatment also decreased the ROS level and inflammation in the cardiomyocytes. Furthermore, 1,25-vitamin D3 pretreatment alleviated COFs-derived PM2.5-evoked elevation of JAK/STAT and NF-κB signaling pathways. Our study showed that 1,25-vitamin D3 pretreatment protected cardiomyocytes from COFs-derived PM2.5-induced injury by decreasing ROS, apoptosis and inflammation level via activations of the JAK/STAT and NF-κB signaling pathways.

Effect of Baseline Nutritional Status on Long-term Multivitamin Use and Cardiovascular Disease Risk: A Secondary Analysis of the Physicians' Health Study II Randomized Clinical Trial

Importance

Long-term multivitamin use had no effect on risk of cardiovascular disease (CVD) in the Physicians' Health Study II. Baseline nutritional status may have modified the lack of effect.

Objective

To investigate effect modification by various baseline dietary factors on CVD risk in the Physicians' Health Study II.

Design, Setting, and Participants

The Physicians' Health Study II was a randomized, double-blind, placebo-controlled trial testing multivitamin use (multivitamin [Centrum Silver] or placebo daily) among US male physicians. The Physicians' Health Study II included 14 641 male physicians 50 years or older, 13 316 of whom (91.0%) completed a baseline 116-item semiquantitative food frequency questionnaire and were included in the analyses. This study examined effect modification by baseline intake of key foods, individual nutrients, dietary patterns (Alternate Healthy Eating Index and Alternate Mediterranean Diet Score), and dietary supplement use. The study began in 1997, with continued treatment and follow-up through June 1, 2011.

Interventions

Multivitamin or placebo daily.

Main Outcomes and Measures

Major cardiovascular events, including nonfatal myocardial infarction, nonfatal stroke, and CVD mortality. Secondary outcomes included myocardial infarction, total stroke, CVD mortality, and total mortality individually.

Results

In total, 13 316 male physicians (mean [SD] age at randomization, 64.0 [9.0] years in those receiving the active multivitamin and 64.0 [9.1] years in those receiving the placebo) were observed for a mean (SD) follow-up of 11.4 (2.3) years. There was no consistent evidence of effect modification by various foods, nutrients, dietary patterns, or baseline supplement use on the effect of multivitamin use on CVD end points. Statistically significant interaction effects were observed between multivitamin use and vitamin B6 intake on myocardial infarction, between multivitamin use and vitamin D intake on CVD mortality, and between multivitamin use and vitamin B12 intake on CVD mortality and total mortality. However, there were inconsistent patterns in hazard ratios across tertiles of each dietary factor that are likely explained by multiple testing.

Conclusions and Relevance

The results suggest that baseline nutritional status does not influence the effect of randomized long-term multivitamin use on major CVD events. Future studies are needed to investigate the role of baseline nutritional biomarkers on the effect of multivitamin use on CVD and other outcomes.

Trial Registration

clinicaltrials.gov Identifier: NCT00270647.

The Free Hormone Hypothesis: Is Free Serum 25-Hydroxyvitamin D a Better Marker for Bone Mineral Density in Older Women?

It is presently unclear whether free serum 25‐hydroxyvitamin D (S‐25(OH)D) better reflects bone health than total S‐25(OH)D. We have previously shown that summer total S‐25(OH)D values are more useful to predict bone mineral density (BMD) than winter values. Our objective was therefore to compare the relative importance of free and total S‐25(OH)D for BMD by season. BMD was measured by dual‐energy X‐ray absorptiometry (DXA) in 5002 Swedish women (mean age 68 years) randomly selected from a large population‐based longitudinal cohort study. Free S‐25(OH)D was analyzed by a commercial ELISA and total S‐25(OH)D by HPLC–tandem mass spectrometry (MS/MS). Free and total S‐25(OH)D co‐varied with season, with 26% and 29% higher values in August compared with those in January–March (nadir). There were no differences in mean BMD between categories of free or total S‐25(OH)D in samples collected during winter. Women with higher total S‐25(OH)D measured during summer had higher BMD at the total hip. Compared with women who had total S‐25(OH)D values above 80 nmol/L during summer, adjusted BMD at the total hip was 6% (95% CI, 1% to 11%) lower for S‐25(OH)D concentrations between 30 and 40 mmol/L, and 11% (95% CI, 3% to 19%) lower for those with total S‐25(OH)D <30 nmol/L. In contrast, free S‐25(OH)D measured during summer was not associated with BMD. Compared with women who had highest free S‐25(OH)D measured during summer (>8.8 pmol/L), those with intermediate (2.4–3.5 pmol/L) and lowest (<2.4 pmol/L) free S‐25(OH)D during summer did not have lower total hip BMD values (3% [95% CI, −2% to 7%] and −2% [95% CI, −8% to 4%]). In addition, we found no added value for the prediction of BMD with the combined measurement of total and free S‐25(OH)D during summer or winter. We conclude that vitamin D status assessed by direct measurements of free S‐25(OH)D does not reflect BMD better than total S‐25(OH)D. © 2018 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

The Evolving Role of Multivitamin/Multimineral Supplement Use among Adults in the Age of Personalized Nutrition

Micronutrient deficiencies occur in segments of the adult population in the United States. Multivitamin/multimineral supplements (MVMS) are widely used by this population, which reduces inadequacies in micronutrient intake, but the potential for exceeding tolerable upper intake levels in others should be considered. There are concerns associated with the excessive intake of certain nutrients, particularly folic acid, and potential untoward consequences. The advent of nutrigenomics and the enhanced ability to directly study the interactions between nutrition and genetic variants and expression will allow for the conduct of more targeted studies with specific endpoints and may ultimately lead to progress in the field of personalized nutrition. The role of MVMS in health maintenance and chronic disease prevention remains controversial. Conducting studies in this area has been hampered by, among other factors, inconsistent definitions of MVMS, ranging from as few as three vitamins to broad-spectrum products containing more than two dozen vitamins and minerals. Results from some observational studies and large-scale, randomized, controlled trials suggest that MVMS may reduce the risk of some forms of cancer and, potentially, cardiovascular disease. The ongoing COcoa Supplement and Multivitamin Outcomes Study (COSMOS) is expected to build on this research and provide additional insights into these areas.

Effects of Multivitamin, Multimineral and Phytonutrient Supplementation on Nutrient Status and Biomarkers of Heart Health Risk in a Russian Population: A Randomized, Double Blind, Placebo Controlled Study

The primary objective of this clinical study was to evaluate the effect of a dietary multivitamin, multimineral and phytonutrient (VMP) supplement on blood nutrient status and biomarkers of heart health risk in a Russian population. One hundred twenty healthy adults (40-70 years) were recruited for a 56-day (eight-week) randomized, double blind, placebo controlled study with parallel design. Subjects were divided into two groups and received either a VMP or a placebo (PLA) supplement. Blood nutrient levels of β-carotene, α-tocopherol, vitamin C, B6, B12, red blood cell (RBC) folate, Zinc and Selenium were measured at baseline and on Days 28 and 56, and quercetin was measured at baseline and on Day 56. Blood biomarkers of heart health, i.e. homocysteine (Hcy), high-sensitivity C-reactive protein (hs-CRP), oxidized LDL (ox-LDL), gamma-glutamyl transferase (GGT), uric acid and blood lipid profile, were measured at baseline and Day 56. Dietary VMP supplementation for 56 days significantly increased circulating levels of quercetin, vitamin C, RBC folate and partially prevented the decline in vitamin B6 and B12 status. Both serum Hcy and GGT were significantly reduced (-3.97 ± 10.09 µmol/L; -1.68 ± 14.53 U/L, respectively) after VMP supplementation compared to baseline. Dietary VMP supplementation improved the nutrient status and reduced biomarkers of heart health risk in a Russian population.

Homocysteine-lowering interventions for preventing cardiovascular events

BACKGROUND

Cardiovascular disease, which includes coronary artery disease, stroke and peripheral vascular disease, is a leading cause of death worldwide. Homocysteine is an amino acid with biological functions in methionine metabolism. A postulated risk factor for cardiovascular disease is an elevated circulating total homocysteine level. The impact of homocysteine-lowering interventions, given to patients in the form of vitamins B6, B9 or B12 supplements, on cardiovascular events has been investigated. This is an update of a review previously published in 2009, 2013, and 2015.

OBJECTIVES

To determine whether homocysteine-lowering interventions, provided to patients with and without pre-existing cardiovascular disease are effective in preventing cardiovascular events, as well as reducing all-cause mortality, and to evaluate their safety.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 5), MEDLINE (1946 to 1 June 2017), Embase (1980 to 2017 week 22) and LILACS (1986 to 1 June 2017). We also searched Web of Science (1970 to 1 June 2017). We handsearched the reference lists of included papers. We also contacted researchers in the field. There was no language restriction in the search.

SELECTION CRITERIA

We included randomised controlled trials assessing the effects of homocysteine-lowering interventions for preventing cardiovascular events with a follow-up period of one year or longer. We considered myocardial infarction and stroke as the primary outcomes. We excluded studies in patients with end-stage renal disease.

DATA COLLECTION AND ANALYSIS

We performed study selection, 'Risk of bias' assessment and data extraction in duplicate. We estimated risk ratios (RR) for dichotomous outcomes. We calculated the number needed to treat for an additional beneficial outcome (NNTB). We measured statistical heterogeneity using the I2 statistic. We used a random-effects model. We conducted trial sequential analyses, Bayes factor, and fragility indices where appropriate.

MAIN RESULTS

In this third update, we identified three new randomised controlled trials, for a total of 15 randomised controlled trials involving 71,422 participants. Nine trials (60%) had low risk of bias, length of follow-up ranged from one to 7.3 years. Compared with placebo, there were no differences in effects of homocysteine-lowering interventions on myocardial infarction (homocysteine-lowering = 7.1% versus placebo = 6.0%; RR 1.02, 95% confidence interval (CI) 0.95 to 1.10, I2 = 0%, 12 trials; N = 46,699; Bayes factor 1.04, high-quality evidence), death from any cause (homocysteine-lowering = 11.7% versus placebo = 12.3%, RR 1.01, 95% CI 0.96 to 1.06, I2 = 0%, 11 trials, N = 44,817; Bayes factor = 1.05, high-quality evidence), or serious adverse events (homocysteine-lowering = 8.3% versus comparator = 8.5%, RR 1.07, 95% CI 1.00 to 1.14, I2 = 0%, eight trials, N = 35,788; high-quality evidence). Compared with placebo, homocysteine-lowering interventions were associated with reduced stroke outcome (homocysteine-lowering = 4.3% versus comparator = 5.1%, RR 0.90, 95% CI 0.82 to 0.99, I2 = 8%, 10 trials, N = 44,224; high-quality evidence). Compared with low doses, there were uncertain effects of high doses of homocysteine-lowering interventions on stroke (high = 10.8% versus low = 11.2%, RR 0.90, 95% CI 0.66 to 1.22, I2 = 72%, two trials, N = 3929; very low-quality evidence).We found no evidence of publication bias.

AUTHORS' CONCLUSIONS

In this third update of the Cochrane review, there were no differences in effects of homocysteine-lowering interventions in the form of supplements of vitamins B6, B9 or B12 given alone or in combination comparing with placebo on myocardial infarction, death from any cause or adverse events. In terms of stroke, this review found a small difference in effect favouring to homocysteine-lowering interventions in the form of supplements of vitamins B6, B9 or B12 given alone or in combination comparing with placebo.There were uncertain effects of enalapril plus folic acid compared with enalapril on stroke; approximately 143 (95% CI 85 to 428) people would need to be treated for 5.4 years to prevent 1 stroke, this evidence emerged from one mega-trial.Trial sequential analyses showed that additional trials are unlikely to increase the certainty about the findings of this issue regarding homocysteine-lowering interventions versus placebo. There is a need for additional trials comparing homocysteine-lowering interventions combined with antihypertensive medication versus antihypertensive medication, and homocysteine-lowering interventions at high doses versus homocysteine-lowering interventions at low doses. Potential trials should be large and co-operative.

Dietary supplement use in the older population of Iceland and association with mortality

Dietary supplements are often used by the elderly to improve their nutritional status. However, intake above the recommended dietary levels may be detrimental, and uncertainty exists on the potential health benefits of supplementation in this population. The aim of this study was to describe supplement use among Icelandic older adults and to assess its association with total mortality and CVD-related mortality. This study used data from the Age Gene/Environment Susceptibility-Reykjavik study, which recruited 5764 participants aged 66-98 years in 2002-2006. Intake of vitamins and minerals from dietary supplements was estimated from interviews. Hazard ratios (HR) for mortality were estimated in multivariate analyses with follow-up ending in 2009. The results showed that most (77 %) of the participants used supplements. Overall, the consumption of vitamins and minerals from supplements was moderate although 22 and 14 % of users exceeded the upper recommended intake levels for vitamin B6 and Zn, respectively. Supplement users followed in general a healthier lifestyle than non-users. There were 1221 deaths including 525 CVD-related deaths during the follow-up period. When comparing multivitamin users with non-users in multivariable models, no associations with total mortality (HR 0·91; 95 % CI: 0·77, 1·08) or CVD-related mortality (HR 0·91; 95 % CI 0·70, 1·18) were observed. In conclusion, users of supplements generally lead healthier lifestyles than non-users and supplements did not confer any added advantage or harm relative to mortality risk. However, the intake of vitamin B6 and Zn from dietary supplements exceeded the recommended daily intake for almost a quarter of the supplement users.

The seasonal importance of serum 25-hydroxyvitamin D for bone mineral density in older women

BACKGROUND

The impact of season when determining a serum 25-hydroxyvitamin D (S-25OHD) cut-off level for optimal bone health is unknown.

OBJECTIVE

To investigate the relative importance of S-25OHD for bone mineral density (BMD) by season.

METHODS

A subcohort of 5002 Swedish women (mean age 68 years), randomly selected from a large population-based longitudinal cohort study with repeat dietary and lifestyle information, was enrolled during 2003-2009 for a clinical examination, which included dual-energy X-ray absorptiometry and collection of fasting blood samples. Categories of vitamin D status were determined by S-25OHD (measured by HPLC-MS/MS).

RESULTS

In samples collected during summer, we found a gradual increase in BMD of the total hip up to a S-25OHD level of 40 nmol L^-1 (6% of the cohort). In women with S-25OHD concentrations below 30 nmol L^-1 during summer, adjusted BMD was 11% lower [95% confidence interval (CI) 3-19] and in those with S-25OHD levels of 30-40 nmol L^-1 BMD was 6% lower (95% CI 1-11), compared with women with S-25OHD levels above 80 nmol L^-1 . Low S-25OHD concentrations during summer (<30 nmol L^-1 ) were also associated with higher adjusted relative risk of osteoporosis (4.9; 95% CI 2.9-8.4) compared with concentrations above 80 nmol L^-1 . By contrast, no differences in mean BMD values between categories of S-25OHD were found during winter.

CONCLUSIONS

Summer concentrations of S-25OHD appear to be the most useful to predict BMD, whereas winter levels have limited value. To determine a S-25OHD cut-off level for vitamin D deficiency, it may be necessary to take into account the season of blood collection.

Multivitamin use and the risk of hypertension in a prospective cohort study of women

OBJECTIVE

Despite the widespread use of multivitamin supplements, little is known regarding their effects on blood pressure (BP) and the development of hypertension. We, therefore, sought to prospectively investigate how multivitamin use was associated with incident hypertension among middle-aged and older women.

METHODS

We studied 28 157 women from the Women's Health Study aged at least 45 years and free of cardiovascular disease, cancer, and hypertension at baseline. Women reported information on a wide range of lifestyle, clinical, and dietary factors, including multivitamin and other supplement use at baseline. Hypertension was identified on baseline and annual follow-up questionnaires. Incident hypertension was defined as either a new diagnosis of hypertension by a physician, initiation of antihypertensive medication, newly reported SBP at least 140 mmHg, or DBP at least 90 mmHg during follow-up.

RESULTS

During a mean follow-up of 11.5 years, we identified 16 316 cases of incident hypertension. We found that neither baseline (hazard ratio = 1.03, 95% confidence interval: 1.00, 1.07) nor time-varying multivitamin use (hazard ratio = 0.97, 95% confidence interval: 0.94-1.00) were associated with the risk of incident hypertension in multivariable-adjusted models. When we investigated the duration of multivitamin use reported at baseline, we also observed no association with the risk of hypertension.

CONCLUSION

The results from this prospective study of middle-aged and older women suggest that neither baseline multivitamin use nor time-varying multivitamin use is associated with the risk of developing hypertension.

Multivitamin Use and the Risk of Cardiovascular Disease in Men

BACKGROUND

Although multivitamins are widely used by US adults, few prospective studies have investigated their association with the long- and short-term risks of cardiovascular disease (CVD).

OBJECTIVE

The aim of this study was to investigate how multivitamin use is associated with the risk of CVD in initially healthy men at baseline.

METHODS

We studied 18,530 male physicians aged ≥40 y from the Physicians' Health Study I cohort who were free of CVD and cancer at baseline (1982). All men provided a wide range of self-reported lifestyle and clinical factors plus intake of selected foods and dietary supplements. Cox proportional hazards models were used to calculate multivariable-adjusted HRs (95% CIs).

RESULTS

During a mean follow-up of 12.2 y (total of 225,287 person-years), there were 1697 incident cases of major CVD (defined as nonfatal myocardial infarction, nonfatal stroke, and CVD death). In multivariable-adjusted analyses, no significant associations were observed among baseline multivitamin users compared with nonusers for the risk of major CVD events (HR: 0.94; 95% CI: 0.84, 1.05), whereas a self-reported duration of ≥20 y at baseline was associated with lower risk (HR: 0.56; 95% CI: 0.35, 0.90; P-trend = 0.05). Baseline multivitamin use was also significantly inversely associated with the risk of cardiac revascularization (HR: 0.86; 95% CI: 0.75, 0.98). Baseline use of multivitamins was not significantly associated with other CVD endpoints.

CONCLUSION

In this long-term prospective study in initially healthy men, multivitamin use for ≥20 y was associated with a lower risk of major CVD events.

Vitamin-Mineral Supplement Use Patterns in Elderly Koreans: Data from the 2007-2008 Korean National Health and Nutrition Examination Survey

Background

Vitamin-mineral supplements are the most popular dietary supplements in Korea. However, few studies have assessed the relationship between vitamin-mineral supplementation and associated factors among the Korean elderly. The purpose of this study was to assess the use of vitamin-mineral supplements among elderly in Korea as well as its association with sociodemographic factors, health-related behaviors, medical conditions, and nutrient intake.

Methods

This study was based on data from the Korean National Health and Nutrition Examination Survey, conducted by the Korean Ministry of Health and Welfare from 2008 to 2009. Data from 3,294 elderly men and women (65 years of age and older) were analyzed. Multivariable-weighted logistic regression model analysis was used to evaluate the association between vitamin-mineral supplement use and sociodemographic factors, health-related habits, and medical conditions.

Results

Vitamin-mineral supplementation was reported by 16.3% of the participants. The most common reason for using dietary supplements was recommendations from friends and acquaintances. Highly educated person, female participants had a greater likelihood of taking vitamin-mineral supplements. In addition, analysis of nutrient intake from food sources alone revealed a lower proportion of vitamin-mineral supplement users with nutrient intakes below the estimated average requirements for vitamin A, vitamin C, thiamine, riboflavin, niacin, calcium, iron, and phosphorus, compared to nonusers. However, vitamin-mineral supplementation was not associated with health-related behaviors or medical conditions.

Conclusion

Highly educated person, elderly Korean women had a greater likelihood of using vitamin-mineral supplements. In addition, nutrient intakes from food sources alone were significantly higher among vitamin-mineral supplement users. Finally, vitamin-mineral supplementation may be an indicator of healthier diet in elderly Koreans.

Efficacy of Multivitamin/mineral Supplementation to Reduce Chronic Disease Risk: A Critical Review of the Evidence from Observational Studies and Randomized Controlled Trials

We reviewed recent scientific evidence regarding the effects of multivitamin/mineral (MVM) supplements on risk of chronic diseases, including cancer, cardiovascular disease, and age-related eye diseases. Data from randomized controlled trials (RCTs) and observational, prospective cohort studies were examined. The majority of scientific studies investigating the use of MVM supplements in chronic disease risk reduction reported no significant effect. However, the largest and longest RCT of MVM supplements conducted to date, the Physicians' Health Study II (PHS II), found a modest and significant reduction in total and epithelial cancer incidence in male physicians, consistent with the Supplémentation en Vitamines et Minéraux Antioxydants (SU.VI.MAX) trial. In addition, PHS II found a modest and significant reduction in the incidence of nuclear cataract, in agreement with several other RCTs and observational, prospective cohort studies. The effects of MVM use on other subtypes of cataract and age-related macular degeneration remain unclear. Neither RCTs nor prospective cohort studies are without their limitations. The placebo-controlled trial design of RCTs may be inadequate for nutrient interventions, and residual confounding, measurement error, and the possibility of reverse causality are inherent to any observational study. National surveys show that micronutrient inadequacies are widespread in the US and that dietary supplements, of which MVMs are the most common type, help fulfill micronutrient requirements in adults and children.

The possible importance of income and education as covariates in cohort studies that investigate the relationship between diet and disease

BACKGROUND

  Many cohort studies have been carried out that have provided information on the relationship between diet and health-related outcomes. Omission of important covariates during multivariate analysis may give rise to error due to residual confounding. A possibly important covariate is socioeconomic status (SES) as this is related to both diet and health.

OBJECTIVE

To determine the frequency with which different measures of SES are included as covariates during multivariate analysis of cohort studies that investigated the relationship between diet and health.

METHODOLOGY

  An analysis was carried out of 76 randomly selected papers from 66 cohort studies. The papers covered many dietary variables and a wide variety of diseases/health-related outcomes. The cohort studies were carried out in many different locations and the subjects varied widely in age.

RESULTS

  Approximately two-thirds of the papers (65.8%) used at least one measure of SES as a covariate. Education was used most often (60.5% of papers), followed by income (14.4%) and social class (2.6%). More than one measure of SES was used in 11.8% of papers.

CONCLUSIONS

  Failure to include income (or another measure of present SES, such as occupation) may be a common source of error in cohort studies. Over-reliance on education may be particularly important as it is likely to be a weaker measure of present SES than is income. There is a need for more research on this question. SES in childhood is almost never included in multivariate analysis in cohort studies carried out on adults. This could also play a significant role in disease risk in middle age or later. Very little is known regarding whether this is also a source of residual confounding.

Lack of association of oral calcium supplementation with coronary artery calcification in rheumatoid arthritis

OBJECTIVE

To investigate the association between oral calcium supplementation and coronary artery calcification among rheumatoid arthritis (RA) patients without known cardiovascular disease (CVD).

METHODS

This study was conducted as a nested, prospective cohort study of RA patients without known CVD. The daily supplemental calcium dose was ascertained from each patients' list of prescription and over-the-counter medications at baseline and at visit 2 (median 20 months postbaseline). The coronary artery calcium (CAC) score, a measure of coronary atherosclerosis, was assessed by cardiac multidetector row computed tomography at baseline and at visit 3 (median 39 months postbaseline). The association between calcium supplementation and CAC was explored.

RESULTS

Among the 145 RA patients studied, 42 (28%) were taking ≥1,000 mg/day of supplemental calcium at baseline. A CAC score of >100 units was seen in 44 patients (30%) at baseline and 50 patients (34%) at followup. Baseline CAC scores of >100 units were significantly less frequent in patients receiving the higher dosage (≥1,000 mg/day) of supplemental calcium than in those receiving the lower dosage (<1,000 mg/day) (odds ratio [OR] 0.28, 95% confidence interval [95% CI] 0.11-0.74); this association remained significant after adjustment for relevant confounders (adjusted OR 0.30, 95% CI 0.09-0.93). Similarly, at the third study visit, CAC scores of >100 units were less frequent in the higher supplemental calcium dose group compared to the lower dose group (OR 0.41, 95% CI 0.18-0.95); however, after adjustment for relevant confounders, the statistical significance of this association was lost (adjusted OR 0.39, 95% CI 0.14-1.12). No effect of sex heterogeneity was seen in the association of calcium supplementation with coronary artery calcification, and no change in the CAC score over time was observed.

CONCLUSION

Higher levels of oral calcium supplementation were not associated with an increased risk of coronary atherosclerosis, as measured by the CAC score, in this RA cohort.

Is vitamin supplementation appropriate in the healthy old?

PURPOSE OF REVIEW

Vitamin supplements are used by large numbers of older adults. Although vitamins serve several functions in the body, the benefits or harm of routine supplementation are far from clear. Data from studies over the last decade are reviewed to enable an understanding.

RECENT FINDINGS

Summarized data from studies conducted over the last few years, pertinent to the use of vitamins, as multivitamin combinations and as individual vitamins specifically A, D, E, C, and the B group, are presented. This review targets the benefits and harm of multivitamins when used to lower the risk of cancer, cardiovascular and cerebrovascular disease, visual disorders (e.g., cataracts and age-related macular degeneration), and bone disease. The effects of vitamins on total mortality are discussed. In addition, isolated or multiple vitamin deficiencies, their predisposing settings and manifestations from mild-to-life-threatening illness are discussed.

SUMMARY

Data from studies demonstrate considerable variations, most confirming little to no benefit following supplementation in healthy adults. However, clear roles exist for vitamin supplementation in states of deficiency and in subgroups of older adults at high risk for deficiency of specific or multiple vitamins. In these settings, vitamin supplements help prevent or correct deficiency and related manifestations.

Multivitamin-mineral use is associated with reduced risk of cardiovascular disease mortality among women in the United States

BACKGROUND

Multivitamin-mineral (MVM) products are the most commonly used supplements in the United States, followed by multivitamin (MV) products. Two randomized clinical trials (RCTs) did not show an effect of MVMs or MVs on cardiovascular disease (CVD) mortality; however, no clinical trial data are available for women with MVM supplement use and CVD mortality.

OBJECTIVE

The objective of this research was to examine the association between MVM and MV use and CVD-specific mortality among US adults without CVD.

METHODS

A nationally representative sample of adults from the restricted data NHANES III (1988-1994; n = 8678; age ≥40 y) were matched with mortality data reported by the National Death Index through 2011 to examine associations between MVM and MV use and CVD mortality by using Cox proportional hazards models, adjusting for multiple potential confounders.

RESULTS

We observed no significant association between CVD mortality and users of MVMs or MVs compared with nonusers; however, when users were classified by the reported length of time products were used, a significant association was found with MVM use of >3 y compared with nonusers (HR: 0.65; 95% CI: 0.49, 0.85). This finding was largely driven by the significant association among women (HR: 0.56; 95% CI: 0.37, 0.85) but not men (HR: 0.79; 95% CI: 0.44, 1.42). No significant association was observed for MV products and CVD mortality in fully adjusted models.

CONCLUSIONS

In this nationally representative data set with detailed information on supplement use and CVD mortality data ∼20 y later, we found an association between MVM use of >3 y and reduced CVD mortality risk for women when models controlled for age, race, education, body mass index, alcohol, aspirin use, serum lipids, blood pressure, and blood glucose/glycated hemoglobin. Our results are consistent with the 1 available RCT in men, indicating no relation with MVM use and CVD mortality.

Homocysteine-lowering interventions for preventing cardiovascular events

BACKGROUND

Cardiovascular disease, which includes coronary artery disease, stroke and congestive heart failure, is a leading cause of death worldwide. Homocysteine is an amino acid with biological functions in methionine metabolism. A postulated risk factor is an elevated circulating total homocysteine level, which is associated with cardiovascular events. The impact of homocysteine-lowering interventions, given to patients in the form of vitamins B6, B9 or B12 supplements, on cardiovascular events. This is an update of a review previously published in 2009 and 2013.

OBJECTIVES

To determine whether homocysteine-lowering interventions, provided in patients with and without pre-existing cardiovascular disease are effective in preventing cardiovascular events, as well as all-cause mortality and evaluate their safety.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 1), MEDLINE (1950 to January week 5 2014), EMBASE (1980 to 2014 week 6) and LILACS (1986 to February 2014). We also searched Web of Science (1970 to 7 February 2014). We handsearched the reference lists of included papers. We also contacted researchers in the field. There was no language restriction in the search.

SELECTION CRITERIA

We included randomised controlled trials assessing the effects of homocysteine-lowering interventions for preventing cardiovascular events with a follow-up period of one year or longer. We considered myocardial infarction and stroke as the primary outcomes. We excluded studies in patients with end-stage renal disease.

DATA COLLECTION AND ANALYSIS

We performed study selection, 'Risk of bias' assessment and data extraction in duplicate. We estimated risk ratios (RR) for dichotomous outcomes. We measured statistical heterogeneity using the I(2) statistic. We used a random-effects model.

MAIN RESULTS

In this second updated Cochrane Review, we identified no new randomised controlled trials. Therefore, this new version includes 12 randomised controlled trials involving 47,429 participants. In general terms, 75% (9/12) trials had a low risk of bias. Homocysteine-lowering interventions compared with placebo did not significantly affect non-fatal or fatal myocardial infarction (1743/23,590 (7.38%) versus 1247/20,190 (6.17%); RR 1.02, 95% confidence interval (CI) 0.95 to 1.10, I(2) = 0%, high quality evidence), stroke (968/22,348 (4.33%) versus 974/18,957 (5.13%); RR 0.91, 95% CI 0.82 to 1.0, I(2) = 11%, high quality evidence) or death from any cause (2784/22,648 (12.29%) versus 2502/19,250 (10.64%); RR 1.01, 95% CI 0.96 to 1.07, I(2) = 6%, high quality evidence). Homocysteine-lowering interventions compared with placebo did not significantly affect serious adverse events (cancer) (1558/18,130 (8.59%) versus 1334/14,739 (9.05%); RR 1.06, 95% CI 0.98 to 1.13; I(2) = 0%, high quality evidence).

AUTHORS' CONCLUSIONS

This second update of this Cochrane Review found no evidence to suggest that homocysteine-lowering interventions in the form of supplements of vitamins B6, B9 or B12 given alone or in combination should be used for preventing cardiovascular events. Furthermore, there is no evidence to suggest that homocysteine-lowering interventions are associated with an increased risk of cancer.

The possible importance of income and education as covariates in cohort studies that investigate the relationship between diet and disease

Background:  Many cohort studies have been carried out that have provided information on the relationship between diet and health-related outcomes. Omission of important covariates during multivariate analysis may give rise to error due to residual confounding. A possibly important covariate is socioeconomic status (SES) as this is related to both diet and health.

Objective: To determine the frequency with which different measures of SES are included as covariates during multivariate analysis of cohort studies that investigated the relationship between diet and health.

Methodology:  An analysis was carried out of 76 randomly selected papers from 66 cohort studies. The papers covered many dietary variables and a wide variety of diseases/health-related outcomes. The cohort studies were carried out in many different locations and the subjects varied widely in age.

Results:  Approximately two-thirds of the papers (65.8%) used at least one measure of SES as a covariate. Education was used most often (60.5% of papers), followed by income (14.4%) and social class (2.6%). More than one measure of SES was used in 11.8% of papers.

Conclusions:  Failure to include income (or another measure of present SES, such as occupation) may be a common source of error in cohort studies. Over-reliance on education may be particularly important as it is likely to be a weaker measure of present SES than is income. There is a need for more research on this question. SES in childhood is almost never included in multivariate analysis in cohort studies carried out on adults. This could also play a significant role in disease risk in middle age or later. Very little is known regarding whether this is also a source of residual confounding.

Multivitamin use and cardiovascular disease in a prospective study of women

BACKGROUND

Although multivitamins are widely used, there are limited prospective studies investigating their association with both long- and short-term risk of cardiovascular disease (CVD).

OBJECTIVE

The objective was to investigate how multivitamin use is associated with the long- and short-term risk of CVD.

DESIGN

A prospective cohort study was conducted of 37,193 women from the Women's Health Study aged ≥45 y and free of CVD and cancer at baseline who were followed for an average of 16.2 y. At baseline, women self-reported a wide range of lifestyle, clinical, and dietary factors. Women were categorized into 1) no current use and 2) current use of multivitamins. Duration and updated measures over the course of the follow-up to address short-term effects were also considered. Women were followed for major CVD events, including myocardial infarction (MI), stroke, and CVD death.

RESULTS

During the follow-up, 1493 incident cases of CVD [defined as myocardial infarction (MI), stroke, and CVD death] occurred. In multivariable analyses, multivitamin use compared with no use was not associated with major CVD events (HR: 1.01; 95% CI: 0.89, 1.15), MI (HR: 1.04; 95% CI: 0.84, 1.27), stroke (HR: 0.99; 95% CI: 0.83, 1.18), or CVD death (HR: 1.10; 95% CI: 0.84, 1.45). A nonsignificant inverse association was observed between baseline multivitamin use and major CVD events among women aged ≥70 y (P-interaction = 0.04) and those consuming <3 servings/d of fruit and vegetables (P-interaction = 0.01). When updating information on multivitamin use during the course of follow-up, no associations were observed for major CVD events (HR: 0.91; 95% CI: 0.82, 1.02), MI (HR: 0.89; 95% CI: 0.74, 1.06), stroke (HR: 0.91; 95% CI: 0.78, 1.06), and CVD death (HR: 0.91; 95% CI: 0.71, 1.16).

CONCLUSIONS

In this study of middle-aged and elderly women, neither baseline nor time-varying multivitamin use was associated with the long-term risk of major CVD events, MI, stroke, cardiac revascularizations, or CVD death. Additional studies are needed to clarify the role of multivitamins on CVD.

Prevalence of hyperhomocysteinemia in China: a systematic review and meta-analysis

Hyperhomocysteinemia (HHcy, total homocysteine concentrations > 15 μmol/L) has been associated with increased risk of many diseases. A systematic review was performed to summarize the prevalence of HHcy in China. We searched multiple international and Chinese scientific databases for relevant literature, and further manually screened reference lists and corresponded with original authors. Pooled prevalence of HHcy was calculated using random effects model. Subgroup analysis, meta-regression and sensitivity analysis were also performed. A total of 36 studies consisting 60,754 subjects (57.3% male; age range, 3–97 years) were finally included. The overall pooled prevalence of HHcy was 27.5%. Geographically, the prevalence was high in north areas, intermediate in central areas, and low in south areas, and was higher in inland versus coastal areas. The prevalence increased with age and was significantly higher in men than in women. Rural residents had a slightly higher HHcy prevalence than urban residents, and the studies conducted during 2006 to 2012 presented a higher HHcy prevalence than those during 1990 to 2005. In summary, the prevalence of HHcy in China is high, particularly in northern populations, the inlanders, males, and the elderly. Homocysteine-lowering strategies are necessary to reduce this highly preventable disorder.

The role of homocysteine-lowering B-vitamins in the primary prevention of cardiovascular disease

Cardiovascular disease (CVD) is the leading cause of mortality in the Western world. The effort of research should aim at the primary prevention of CVD. Alongside statin therapy, which is maintained to be an effective method of CVD prevention, there are alternative methods such as vitamin B substitution therapy with folic acid (FA), and vitamins B12 and B6 . B-vitamins may inhibit atherogenesis by decreasing the plasma level of homocysteine (Hcy)-a suspected etiological factor for atherosclerosis-and by other mechanisms, primarily through their antioxidant properties. Although Hcy-lowering vitamin trials have failed to demonstrate beneficial effects of B-vitamins in the prevention of CVD, a meta-analysis and stratification of a number of large vitamin trials have suggested their effectiveness in cardiovascular prevention (CVP) in some aspects. Furthermore, interpretation of the results from these large vitamin trials has been troubled by statin/aspirin therapy, which was applied along with the vitamin substitution, and FA fortification, both of which obscured the separate effects of vitamins in CVP. Recent research results have accentuated a new approach to vitamin therapy for CVP. Studies undertaken with the aim of primary prevention have shown that vitamin B substitution may be effective in the primary prevention of CVD and may also be an option in the secondary prevention of disease if statin therapy is accompanied by serious adverse effects. Further investigations are needed to determine the validity of vitamin substitution therapy before its introduction in the protocol of CVD prevention.

Addressing nutritional gaps with multivitamin and mineral supplements

A balanced and varied diet is the best source of essential vitamins and minerals; however, nutrient deficiencies occur, including in populations with bountiful food supplies and the means to procure nutrient-rich foods. For example, the typical American diet bears little resemblance to what experts recommend for fruit, vegetables, and whole grains, which serve as important sources of an array of vitamins and minerals. With time, deficiencies in one or more micronutrients may lead to serious health issues. A common reason people take multivitamin and mineral (MVM) supplements is to maintain or improve health, but research examining the effectiveness of MVMs in the prevention of certain chronic conditions is ongoing. In addition to the utility of MVMs for filling in relatively small but critical nutritional gaps, which may help prevent conditions such as anemia, neural tube defects, and osteoporosis, some evidence supports possible benefits of MVM supplementation with regard to cancer prevention (particularly in men) and prevention or delay of cataract, as well as some aspects of cognitive performance. Unlike some single-vitamin supplements, MVM supplements are generally well tolerated and do not appear to increase the risk of mortality, cerebrovascular disease, or heart failure. The potential benefits of MVM supplements likely outweigh any risk in the general population and may be particularly beneficial for older people.

A systematic review of multivitamin-multimineral use and cardiovascular disease and cancer incidence and total mortality

Multivitamin-multimineral (MVM) supplements are the most frequently used dietary supplements in the United States, with one third or more of the population using at least one daily. However, the health-related implications of MVM use are unclear. Thus, we systematically reviewed and summarized the prospective studies of MVM supplementation and all-cause and cause-specific mortality, as well as cardiovascular disease (CVD) and cancer incidence, to critically evaluate the current evidence on this topic. We included studies of generally healthy adult populations that evaluated multivitamin (the most commonly used dietary supplement) and/or multimineral supplement use or simultaneous use of 3 or more vitamins and minerals. We did not evaluate individual supplements. A total of 12 cohort studies and 3 primary prevention randomized controlled trials met our inclusion criteria. The majority of the studies were conducted in the United States (n = 11), and the remaining were conducted in European countries (n = 3) and Japan (n = 1). Although between-study methodological variation was present, most relative risks hovered closely around or slightly below the null value. No clear patterns of associations by study country, gender, smoking status, or frequency of use were observed. Based upon the available scientific evidence to date, supplementation with MVMs does not appear to increase all-cause mortality, cancer incidence or mortality, or CVD incidence or mortality and may provide a modest protective benefit.

Intake and serum concentrations of α-tocopherol in relation to fractures in elderly women and men: 2 cohort studies

BACKGROUND

A reduction in the formation of free radicals and oxidative stress might reduce the rate of bone loss and muscle wasting.

OBJECTIVE

The objective was to determine whether α-tocopherol intake or serum concentrations are associated with fracture risk in older women and men.

DESIGN

Two cohort studies, the Swedish Mammography Cohort (SMC; n = 61,433 women) and the Uppsala Longitudinal Study of Adult Men (ULSAM; n = 1138 men), were used.

RESULTS

During 19 y of follow-up, 14,738 women in the SMC experienced a first fracture at any site (3871 hip fractures). A higher hip fracture rate was observed with lower intakes of α-tocopherol. Compared with the highest quintile of intake, the lowest quintile had a multivariable-adjusted HR of 1.86 (95% CI: 1.67, 2.06). The HR of any fracture was 1.20 (95% CI: 1.14, 1.28). α-Tocopherol-containing supplement use was associated with a reduced rate of hip fracture (HR: 0.78; 95% CI: 0.65, 0.93) and any fracture (HR: 0.86; 95% CI: 0.78, 0.94). Compared with the highest quintile of α-tocopherol intake in ULSAM (follow-up: 12 y), lower intakes (quintiles 1-4) were associated with a higher rate of hip fracture (HR: 3.33; 95% CI: 1.43, 7.76) and any fracture (HR: 1.84; 95% CI: 1.18, 2.88). The HR for hip fracture in men for each 1-SD decrease in serum α-tocopherol was 1.58 (95% CI: 1.13, 2.22) and for any fracture was 1.23 (95% CI: 1.02, 1.48).

CONCLUSION

Low intakes and low serum concentrations of α-tocopherol are associated with an increased rate of fracture in elderly women and men.

Who uses multivitamins? A cross-sectional study in the Physicians' Health Study

PURPOSE

The aim of this study was to examine the prevalence of self-reported multivitamin use in the Physicians' Health Study (PHS) cohort and its association with various lifestyle, clinical, and dietary factors to improve our understanding of who tends to use multivitamins.

METHODS

Among 18,040 middle-aged and older men, information on lifestyle and clinical factors was collected from a baseline enrollment questionnaire, and supplement use and dietary factors were assessed through a food-frequency questionnaire. Four categories of multivitamin use were considered: (1) no supplement use, (2) use of multivitamins only, (3) use of multivitamins with other individual vitamin/mineral supplements, and (4) use of other supplements only. We used logistic regression to calculate multivariate odds ratios and 95% confidence intervals of taking multivitamin supplements for various lifestyle, clinical and dietary factors.

RESULTS

Overall, 36% of men reported current multivitamin use. Men who were older, current smokers, and currently using aspirin were 143, 43, and 74% more likely to use multivitamins only. Men having a history of hypercholesterolemia were 16% more likely to use multivitamins only. A 14, 24, and 26% greater likelihood of using multivitamins was also observed among men consuming more fruits and vegetables, whole grains, and tea, respectively. Similar associations were observed for the likelihood of using multivitamins with other supplements; however, men with higher physical activity, history of cancer, hypertension, higher consumption of nuts, and lower consumption of red meat and coffee were also more likely to use multivitamins with other supplements (all P < 0.05).

CONCLUSION

Self-reported multivitamin use associated with lifestyle, clinical and dietary factors may be an indicator of healthy behaviors. These results provide important information for the interpretation of the recent findings from the PHS II trial and consideration of results from observational studies of multivitamin use and chronic disease.

An industry perspective: dietary supplements and mortality rates in older women

This special article seeks to provide balance and clarity to the confusion brought about by the conclusions resulting from a recent study published in Archives of Internal Medicine by Mursu et al. (2011). An examination of three key limitations of the study provides context to why additional research is needed: (a) Nonusers were poorly defined; (b) supplement users were healthier than nonusers; and (c) the number of supplement users increased throughout the study. Although the literature is limited, other similar observational studies have also shown positive effects on the risk mortality for both multivitamins and single-nutrient supplements. Observational trials are an essential component of evidence-based nutrition but do not offer certainty because other data, such as the one generated from randomized controlled trials, are equally important in regard to the totality of evidence. The Senior Scientific Advisory Committee for the Council for Responsible Nutrition, an industry trade group, feels that the conclusions of the study by Mursu et al. (2011) are overstated and suggests that researchers analyze cohort(s) designed to specifically examine vitamin and mineral supplements free of confounding from factors, such as hormone replacement therapy, to better assess their benefits to the general population.

Long term calcium intake and rates of all cause and cardiovascular mortality: community based prospective longitudinal cohort study

OBJECTIVE

To investigate the association between long term intake of dietary and supplemental calcium and death from all causes and cardiovascular disease.

DESIGN

Prospective longitudinal cohort study.

SETTING

Swedish mammography cohort, a population based cohort established in 1987-90.

PARTICIPANTS

61 433 women (born between 1914 and 1948) followed-up for a median of 19 years.

MAIN OUTCOME MEASURES

Primary outcome measures, identified from registry data, were time to death from all causes (n=11 944) and cause specific cardiovascular disease (n=3862), ischaemic heart disease (n=1932), and stroke (n=1100). Diet was assessed by food frequency questionnaires at baseline and in 1997 for 38 984 women, and intakes of calcium were estimated. Total calcium intake was the sum of dietary and supplemental calcium.

RESULTS

The risk patterns with dietary calcium intake were non-linear, with higher rates concentrated around the highest intakes (≥1400 mg/day). Compared with intakes between 600 and 1000 mg/day, intakes above 1400 mg/day were associated with higher death rates from all causes (hazard ratio 1.40, 95% confidence interval 1.17 to 1.67), cardiovascular disease (1 49, 1.09 to 2.02), and ischaemic heart disease (2.14, 1.48 to 3.09) but not from stroke (0.73, 0.33 to 1.65). After sensitivity analysis including marginal structural models, the higher death rate with low dietary calcium intake (<600 mg/day) or with low and high total calcium intake was no longer apparent. Use of calcium tablets (6% users; 500 mg calcium per tablet) was not on average associated with all cause or cause specific mortality but among calcium tablet users with a dietary calcium intake above 1400 mg/day the hazard ratio for all cause mortality was 2.57 (95% confidence interval 1.19 to 5.55).

CONCLUSION

High intakes of calcium in women are associated with higher death rates from all causes and cardiovascular disease but not from stroke.

The impact of dietary counselling during pregnancy on vitamin intake and status of women and their children

We aimed here to assess the impact of dietary counselling during pregnancy on dietary intake of vitamins and the vitamin status of women and their children. At the first trimester of pregnancy, 89 women from allergic families were randomized to a control group (n = 45) or to receive individual dietary counselling (n = 44). Women's vitamin intakes and serum concentrations were analyzed during and after pregnancy. Further, vitamin concentrations were measured from breast milk and infant serum at one month of age. The study is registered as clinical study (NCT00167000; section 3, http://www.clinicaltrials.gov ). Dietary counselling resulted in a higher intake of beta-carotene and vitamin E compared to controls. Further, in women lower serum beta-carotene and higher colostrum vitamin A concentrations were found in the intervention group compared to controls. Dietary counselling during pregnancy improves women's vitamin intakes but does not provide unambiguous effects on vitamin status of women or children.

Multivitamins in the prevention of cardiovascular disease in men: the Physicians' Health Study II randomized controlled trial

CONTEXT

Although multivitamins are used to prevent vitamin and mineral deficiency, there is a perception that multivitamins may prevent cardiovascular disease (CVD). Observational studies have shown inconsistent associations between regular multivitamin use and CVD, with no long-term clinical trials of multivitamin use.

OBJECTIVE

To determine whether long-term multivitamin supplementation decreases the risk of major cardiovascular events among men.

DESIGN, SETTING, AND PARTICIPANTS

The Physicians' Health Study II, a randomized, double-blind, placebo-controlled trial of a common daily multivitamin, began in 1997 with continued treatment and follow-up through June 1, 2011. A total of 14,641 male US physicians initially aged 50 years or older (mean, 64.3 [SD, 9.2] years), including 754 men with a history of CVD at randomization, were enrolled.

INTERVENTION

Daily multivitamin or placebo.

MAIN OUTCOME MEASURES

Composite end point of major cardiovascular events, including nonfatal myocardial infarction (MI), nonfatal stroke, and CVD mortality. Secondary outcomes included MI and stroke individually.

RESULTS

During a median follow-up of 11.2 (interquartile range, 10.7-13.3) years, there were 1732 confirmed major cardiovascular events. Compared with placebo, there was no significant effect of a daily multivitamin on major cardiovascular events (11.0 and 10.8 events per 1000 person-years for multivitamin vs placebo, respectively; hazard ratio [HR], 1.01; 95% CI, 0.91-1.10; P = .91). Further, a daily multivitamin had no effect on total MI (3.9 and 4.2 events per 1000 person-years; HR, 0.93; 95% CI, 0.80-1.09; P = .39), total stroke (4.1 and 3.9 events per 1000 person-years; HR, 1.06; 95% CI, 0.91-1.23; P = .48), or CVD mortality (5.0 and 5.1 events per 1000 person-years; HR, 0.95; 95% CI, 0.83-1.09; P = .47). A daily multivitamin was also not significantly associated with total mortality (HR, 0.94; 95% CI, 0.88-1.02; P = .13). The effect of a daily multivitamin on major cardiovascular events did not differ between men with or without a baseline history of CVD (P = .62 for interaction).

CONCLUSION

Among this population of US male physicians, taking a daily multivitamin did not reduce major cardiovascular events, MI, stroke, and CVD mortality after more than a decade of treatment and follow-up.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00270647.

Relationship between plasma carotenoids, fruit and vegetable intake, and plasma extracellular superoxide dismutase activity in women: different in health and disease?

Abstract Exogenous antioxidants may influence endogenous antioxidant enzyme activity. We observed in healthy women (n = 95) that higher plasma α-carotene, β-carotene, β-cryptoxanthin, sum of plasma carotenoids, and fruit and vegetable intake were associated with lower plasma extracellular-superoxide dismutase activity. In women with a history of cardiovascular disease, diabetes, or cancer (n = 62), we observed no associations. Our observation that plasma extracellular-superoxide dismutase activity was inversely associated with plasma carotenoids and fruit and vegetable intake in healthy women, but not in women with a history of cardiovascular disease, diabetes, or cancer, suggests that the associations between exogenous and endogenous antioxidants may differ in health and disease.