Ezetimibe is a drug that lowers LDL cholesterol by blocking absorption of cholesterol from the digestive track. A recent study compared adding this drug- Vytorin is a combination of Lipitor-like simvastatin and this drug, Zetia, vs adding Niacin. You will have read several things about this study if nowhere else in the WSJ as it will bear on share price of Merck. Now the details of the study are interesting: the study was to see whether further lowering of LDL by the use of ezetimibe slowed down or reversed the thickening of the wall of the carotid artery; a benchmark of vascular disease. Makes sense; LDL is the ‘bad’ cholesterol. Right?
Well the combination of niacin and simvastatin worked much better than simvastatin and ezetimibe. Blah, blah, blah…wait the fun part was that THE LOWER THE LDL GOT THE WORSE THE WALL THICKENING GOT!! Niacin was better in the 14 month trial; by the way it raised HDL more.
Whatever else this should teach us it should remind us that lowering LDL is not a useful endpoint. It can be very misleading. LDL per se is not the ‘mechanism of injury’ in vascular heart disease. OK, now everyone wants to start taking nicain; a simple vitamin (B-3). Hold on and consider:
Vitamin B-9 and Cancer
Folic acid, B9, is often used for heart disease as one of the known risk factors, homocysteine, goes down with folic acid. November 18, 2009 JAMA has an analysis from Norway where folic acid had been used for heart disease for a long time. Well up popped cancer. Number needed to harm, NNH, for folic acid was 63; if 63 people took folic acid 1 additional person got cancer over those who did not take folic acid. For all cause mortality, everything including cancer, the NNH was 43. One extra death for every 43 people who took folic acid. The follow up time for the NNH calculation was 78 months.
Keep in mind prior studies published in the Journal of the National Cancer Institute have shown an increase in prostate cancer in those who take folic acid.
Even with my very critical approach to supplementation I fell for this one and have recommended folic acid in the past; not for several years but not so long ago.
Do you need folic acid? Of course you do. Should you take it? I wouldn’t. Get it from food. Should you take niacin? I wouldn’t. Studies already done have shown niacin increasing the incidence of liver cancer. These studies have been dismissed. But the mechanism makes sense.
Fads and Vitamin D
The newest must have vitamin is D. Many studies have shown the majority of Americans have dangerously low vitamin D levels. The same guys who brought you the lovely unintended consequence of low vitamin D by scaring everyone about the dangers of the sun- for crying out loud you can’t even buy basic cosmetics without sun block in them- now tell you everyone needs vitamin D supplementation.
Well I believe the ‘everyone is too low’ part of the story but I would be very careful about the ‘everyone needs to take vitamin D’ part of the story.
Check your levels and supplement until they are in a good therapeutic range and then get off them and get some sun. And while you are out there…just breathe.
What is The Connection, What is The Point?
Science is a very powerful tool and is arguably if not tautologically the only way to know how the world works. Still its findings must be accepted, tempered, by a different concept; humility. The complexity of the human animal is, at a practical level, incalculable. Don’t get me started on mathematical reductionism and its place in understanding system functions; this for those mathematicians and physicists reading this. It won’t do to ‘explain’ at the practical level.
Humility will remind us that foods and the way our bodies use them are far more complex than we understand and that our best guidelines for ‘supplementation’ come from our anthropological history; we are hunter gatherers. Eat fresh, whole foods from a variety of sources; do not become ideological about diet or supplementation. Be fierce, I did not say violent, and breathe.
