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The number of deaths from coronary heart disease among Japanese men is less than half that of American men. Whether this effect is due to genetic, dietary or other factors has not been confirmed. In the first international study of its kind, published in the August 5, 2008, issue of Journal of the American College of Cardiology, University of Pittsburgh Graduate School of Public Health assistant professor of epidemiology Akira Sekikawa, MD, PhD, and colleagues evaluated data from 868 men aged 40 to 49 enrolled in the ERA JUMP (Electron-Beam Tomography, Risk Factor Assessment Among Japanese and U.S. Men in the Post-World War II Birth Cohort) Study. Two hundred eight-one of the current study’s subjects were from Japan; 306 were Caucasian men from Pennsylvania; and 281 were Japanese-American men living in Hawaii. Blood tests measured total fatty acids and the omega-3 fatty acids eicosapentaenoic, docosahexaenoic and docosapentaenoic acids which are commonly obtained by consuming fish. Ultrasound examination assessed carotid artery intima-medial thickness (IMT), which is used to evaluate atherosclerosis. Coronary artery calcification (CAC) in the heart’s arteries, which also identifies heart disease, was assessed via electron-beam CT scanner.

Dr Sekikawa’s team found that although total fatty acid levels were similar among all subjects, the percentage of fish-based omega-3 fatty acids was twice as high among Japanese men compared with Americans of both European and Japanese descent. Japanese men had significantly less atherosclerosis, as indicated by lower average intima-media thickness and coronary artery calcification. Among Japanese men, intima-media thickness values declined with rising omega-3 fatty acid levels, a phenomenon that was not observed in either American group.

“The death rate from coronary heart disease in Japan has always been puzzlingly low,” Dr Sekikawa observed. “Our study suggests that the very low rates of coronary heart disease among Japanese living in Japan may be due to their lifelong high consumption of fish. Our study clearly demonstrated that whites and Japanese-Americans have similar levels of atherosclerosis, which are much higher than in the Japanese in Japan. This indicates that much lower death rates from coronary heart disease in the Japanese in Japan is very unlikely due to genetic factors.”

“Our study suggests that very high levels of omega-3 fatty acids have strong properties that may help prevent the buildup of cholesterol in the arteries,” Dr Sekikawa stated. “Increasing fish intake to two times a week for healthy people is currently recommended in the U.S. Our study shows much higher intake of fish observed in the Japanese [approximately 3 ounces daily] may have strong anti-atherogenic effect.”

“While we don’t recommend Americans change their diets to eat fish at these quantities because of concerns about mercury levels in some fish, increasing intake of omega-3 fatty acids in the U.S. could have a very substantial impact on heart disease,” he added.

It’s just before noon, and the emergency room already is filling with patients.

John Whitcomb, a lanky, high-octane physician, scurries from exam room to exam room, keeping pace with an onslaught of people coming in with chest pain, ankle injuries, seizures and stomachaches. The ER at Aurora Sinai Medical Center in Milwaukee isn’t the most likely place to get a friendly lecture about vitamin D.

But Whitcomb, one of a small but growing number of physicians who think deficiency of the sunshine vitamin is its own public health emergency, preaches to anyone who will listen.

A growing body of research suggests that inadequate vitamin D can substantially increase the risk of a variety of diseases, including several cancers, heart disease, high blood pressure, diabetes, depression and multiple sclerosis as well as the risk of falling and infections.

In northern regions like Wisconsin, where vitamin D levels are low, the concern is even more pronounced because of a lack of ultraviolet radiation during much of the year.

Now pockets of physicians here and around the country are making vitamin D a high priority.

Steve Trapp, 38, was on a bus from Chicago to Seattle last month when he began vomiting at the Milwaukee bus station. He was taken to the ER at Aurora Sinai. Whitcomb diagnosed the problem as a bout of stomach flu and dispensed nausea medicine — and an ample dose of vitamin D advice.

As Trapp lay in an exam room, Whitcomb rattled off a few recent research findings on how vitamin D can reduce the risk of various diseases. He told the couple how there really is no food source that can provide ample levels of the vitamin.

He said the sun’s angle drops in winter, and with that shift, vitamin D levels in the blood decrease from an average of about 40 nanograms per milliliter to less than 20 ng/ml.

“When the level drops below 32, many of the body’s functions don’t work right,” he said.

Only supplements or ultraviolet light can prevent that from happening.

Over the past two years, Whitcomb estimates that he has talked to more than 1,000 patients about vitamin D in the ER or other urgent care facilities in the area. He’s written about vitamin D in newsletters and given talks to other doctors.

He’s even tested the blood of ER patients to find out their vitamin D levels. Invariably, the levels are extremely low.

While there is not unanimous agreement on what is the optimal vitamin D blood level, many researchers say it should be at least 30 ng/ml and preferably between 40 and 60.

No large clinical trials

Exposure to intense sunlight was mostly a year-round occurrence for our prehistoric ancestors who, for thousands of years, existed naked near the equator.

It has been only in relatively recent human evolutionary history that people moved north, began wearing clothing and spent more time indoors, resulting in vitamin D deficiencies.

The vitamin actually is a hormone that plays a role in the regulation of more than 100 genes, many of which are involved in preventing diseases.

However, while that theory sounds attractive to vitamin D advocates, much of the research pointing to the vitamin’s disease-preventing ability is observational in nature. While most of those studies show a benefit, some do not.

Nevertheless, observational studies pointing to potential health benefits from the vitamin continue to pile up.

A study released late last month found higher rates of death from all causes and from cardiovascular disease among a group of 3,258 heart patients with low levels of vitamin D in their blood, compared with heart patients with higher levels of vitamin D.

Also in June, a study involving 18,225 men found that those with vitamin D levels below 15 ng/ml were 2.4 times more likely to have a heart attack than those with levels above 30 ng/ml.

Last year, an analysis involving 1,760 women found a 50% reduction in breast cancer risk in those whose vitamin D levels were more than 52 ng/ml, compared with levels of less than 13.

After reading a variety of vitamin D studies, Tara Rakowski, an east side family practice physician with Columbia St. Mary’s, began testing for the vitamin in her patients. In more than 60% of the approximately 500 patients, vitamin D levels were less than 20 ng/ml, she said. Now, “there isn’t a patient I don’t check it on,” she said.

Typically she will put patients with low vitamin D levels on a prescription regimen of 50,000 international units of vitamin D a week. After that, they usually take 2,000 IU a day in the form of vitamin D3, which is inexpensive. That’s the dose many vitamin D proponents now are recommending, although it is considerably more than the current recommended intake, which ranges from 200 IU in children to 600 IU in the elderly.

Rakowski said her patients often feel better after boosting their vitamin D levels.

Jaishree Hariharan, an internal medicine physician who practices at Froedtert Hospital, said she had checked vitamin D levels in about 200 patients in the past year. Most have levels below 20 ng/ml, she said.

“The big misnomer that most physicians are worried about is vitamin D toxicity,” said Hariharan, an associate professor of medicine at the Medical College of Wisconsin. However, with doses of 2,000 IU a day, “there is no downside,” she said.

Upping her dose

Alice Carter, a 63-year-old from Milwaukee, is lying on a bed with chest pain in the ER at Sinai Medical Center.

After Whitcomb determines the Milwaukee woman is having a bout of angina, he begins telling her about vitamin D.

He seems pleasantly surprised when she tells him that she started taking 1,000 IU a day about a year ago, but he says she should up the dose to 2,000.

“Your skin pigment protects you from sunburn, but it also means you need to get three to four times as much sunlight to make the same amount of vitamin D,” he tells Carter, who is African-American.

He tells her that many African-Americans he has tested have vitamin D levels of less than 10, but blacks living near the equator in Africa have levels near 60, he says.

“So are you saying I need to move down South?” she jokes.

Whitcomb says that won’t be necessary if she increases her summertime dose to 2,000 IU and her wintertime dose to 4,000.

USA TODAY

07-14-08

The chiseled body of 41-year-old Olympic swimmer Dara Torres was all the talk of people watching the U.S. Olympic trials.

And it prompted some middle-aged people to think about their own physical condition and wonder whether mere mortals can achieve that high level of fitness and end up looking like Torres.

“Many people in their 40s could look like her, but they’d have to train a ridiculous number of hours, and most people in the U.S. would have to lose a lot of weight,” says Timothy Church, director of preventive medicine research at the Pennington Biomedical Research Center in Baton Rouge and co-author of the exercise book Move Yourself.

“It would have to be your mission in life. You’d have to do a minimum of two hours of hard, hard training a day, but probably more like four hours a day. And you’d have to really reduce how much you’d eat. You can build muscle, but if it’s covered in fat, you can’t see it.”

That would be hard for people who juggle a job, family and other responsibilities, he says.

Genetics and age play a big role in how difficult it would be to achieve a high level of fitness, he says. It’s much easier to attain if you have great genes, are in your 20s, naturally have a lot of muscle and have never gained extra weight.

That’s true, says Miriam Nelson, director of the John Hancock Center for Physical Activity and Nutrition at Tufts University in Boston and co-author of Strong Women Stay Young.

If you want to be a competitive athlete, you’ll be training most of the day, she says. And you have to make sure you are doing it correctly so you don’t hurt yourself.

Torres, who has a 2-year-old daughter, does one intense swim workout a day. She also does weight training and dry-land workouts. She has been fit for years, and she has a team that includes two “stretchers” who travel with her, a strength coach and a massage therapist.

Her head coach, Michael Lohberg, says most people may not be able to look like her, “but I really do think with proper nutrition and proper training, people can look very, very fit.”

Americans should be inspired by Torres to increase their strength, aerobic fitness and flexibility, says orthopedic surgeon Angela D. Smith, former president of the American College of Sports Medicine and a National Masters Figure Skating medalist.

Everyone, especially people who have never been very active, must give their bodies time to adapt to a fitness program, she says. “Bones, muscles, ligaments, tendons have to be strengthened gradually by slowly increasing the length and intensity of the workouts.”

People can work with what they have and improve how they look and feel, Smith says. Researchers believe muscle mass plateaus in your mid-40s and then slowly declines unless you do something to preserve it.

Studies show that men ages 50 to 70 who are doing some weight training don’t lose any strength or muscle, Nelson says. And there is research that shows women 50 to 70 can gain muscle if they start lifting weights.

“We don’t have the full picture yet, but data are emerging that suggest that you can preserve much of your strength and fitness well into your 60s and beyond if you work hard enough at it,” Nelson says.

Church used to train more than 20 hours a week for Ironman triathlons, which involve swimming 2.4 miles, biking 112 miles and running a marathon of 26.2 miles in one day.

“When you are super-fit, you just feel invincible. There is no way I could train like that now with a family, and quite frankly I really no longer want to,” says Church, who has two young children.

These days he jogs 30 to 35 minutes two to three days a week. On weekends, he and his wife put their children in a jogger and go out for a fast walk/jog for an hour or more.

If you don’t have the time or inclination to achieve a high fitness level, remember there are great health benefits with moderate amounts of activity, he says. “Thirty minutes a day of walking promotes healthier, happier aging.”