Vitamin D and Bone Health; Infarcts in Middle Age: It's PodMed Double T!

— This week's topics also include bleeding after cannabinoid use, and dietary proteins and mortality

MedpageToday

PodMed Double T is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week. A transcript of the podcast is below the summary.

This week's topics include a bleeding problem after cannabinoid use, infarcts in middle age and cognitive decline, Vitamin D and bone health, and dietary proteins and mortality.

Program notes:

0:41 Animal and plant protein consumption

1:45 More animal protein and more total energy

2:45 Impact of protein on mortality

3:45 Disparage green tea?

4:19 Vitamin D and bone health

5:19 Reduction in bone strength with higher doses

6:17 Infarcts in brain and cognition

7:18 Those with both small and large infarcts at highest risk

8:18 Hypothesis is big and small vessel disease

9:07 Bleeding and cannabinoid use

10:08 Blood was thin and treatment begun

11:51 End

Transcript:

Elizabeth Tracey: More about eating plant-based proteins.

Rick Lange, MD: Does high-dose vitamin D improve bone health?

Elizabeth: If you've got little areas where your brain looks like it's been compromised, what's that have to do with your cognition?

Rick: And thin blood after cannabinoid use.

Elizabeth: That's what we're talking about this week on PodMed TT, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I'm Elizabeth Tracey, a medical journalist at Johns Hopkins, and this will be posted on September 13th, 2019.

Rick: And I'm Rick Lange, President of the Texas Tech University Health Sciences Center in El Paso, where I'm also Dean of the Paul L. Foster School of Medicine.

Elizabeth: Rick, how about if we start with this idea of animal and plant protein consumption and all-cause and cause-specific mortality? Gosh, we just talk about this so often. This is in JAMA Internal Medicine.

This was a huge study, almost 71,000 folks in Japan. They entered this study 45 to 74 years of age, no history of cancer, cerebrovascular disease, or heart disease when they entered. And then they took a look until the end of December in 2016, after which almost 12,000+ deaths had taken place. They looked at what did these people eat. In Japan, of course, they ate a whole lot of fish and vegetables and soy kinds of products. They associated that with their death. They calculated intakes of all these different types of animal proteins and plant proteins as a percentage of their total energy that was consumed.

They do admit the participants who consumed more of the plant-based proteins were more likely to regularly drink green tea. I don't know if that's a confounder or not. And they also found that those who consumed more animal protein also tended to consume more total energy.

They had come to a conclusion that there could be an absolute risk reduction at 15 years for death if there was just an isocaloric, so no change in the total number of calories consumed, but a shift of animal protein to plant protein if there was 3% energy from plant protein. So they found that those folks ... and it's not surprising that higher intakes of plant protein were associated with lower total mortality, also with cancer-related mortality, and also that animal proteins that could be given up would be red meats and processed meats; that could also help total cancer-related and cardiovascular-related mortality.

Rick: Two parts to this study. The first was the association of a high-protein diet with mortality because high-protein diets have been associated with some good things: advanced weight loss, improvements in cardiovascular risk factors, including blood pressure, blood lipid, and glycemic regulation. But on the other hand, they also affect macro/micronutrients and also polyphenols.

What this study showed was overall, high-protein diets did not affect morality. But as you highlighted, when they looked at the different types of protein, if somebody had a plant-protein-based diet -- as opposed to a meat-based-protein diet -- it reduced mortality by somewhere around 15% to 20%, and especially if you replaced the red processed meats with the plants. Now, we didn't talk about what those plant proteins are. Do you want to highlight what we're talking about, Elizabeth?

Elizabeth: Oh, I would love to do that. Because before we started to record, we had a little discussion about what in the world is a pulse. It turns out that's, of course, a legume, beans, and peas. Those are good things to eat, for sure. Which other of the ones would you like to mention?

Rick: They mentioned cereals, vegetables, fruits, in addition to the pulses that you mentioned.

Elizabeth: You disparage the idea that green tea drinking might have something to do with it.

Rick: It's hard to match these populations because it wasn't a randomized trial, but there's really not very good data that drinking green tea can lower mortality by as much as 15% to 20%. I think it has a lot to do with the beneficial diet we've talked about.

Elizabeth: Well, since we're talking about things that people consume, let us turn to the Journal of the American Medical Association. This one I thought was really quite interesting, the potential deleterious effects of supplementing with vitamin D.

Rick: Vitamin D has been considered to be beneficial for preventing and treating osteoporosis. However, when you look at the studies, it's only shown to be beneficial in those individuals that have low vitamin D levels. Using vitamin D supplements, in general, hasn't been beneficial in terms of bone health. But about 1 in 30 patients across the U.S. take not only vitamin D, but take high doses of it. A regular dose would be about 400 units, but some people take 4,000 and some as much as 10,000 units. In those individuals, does the ingestion of high-dose vitamin D either improve bone density or does it somehow improve bone strength?

So there were 311 participants in this study that were randomized to receive either 400 international units of vitamin D, 4,000 units, or 10,000 units and followed at baseline, 3 months, and 3 years. When they measured both bone density and bone strength, the individuals that took the higher doses -- particularly the 10,000 units -- actually had a larger reduction in bone density, also a reduction in bone strength.

This goes counter to what you'd think. It looks like the higher doses of vitamin D were associated with both more bone resorption and decreased levels of parathyroid hormone, and that's a hormone that is important for bone strength. So is there an advantage to taking high-dose vitamin D? The answer is no. And in fact, it may be deleterious.

Elizabeth: I think this really illustrates the fact that many, many people are taking supplements and many of them are also taking them with the idea that if a little is good, more must be better. And there really aren't many guidelines with regard to how much of it can you take and is there a danger to taking too much? We've seen this also with massive doses of vitamin C, for example, where people then might develop kidney stones as a result.

Rick: And again, I want our listeners to understand I think the studies are pretty clear. The benefit of vitamin D supplementation is only seen in the treatment of vitamin D deficiency.

Elizabeth: Let's turn then to Annals of Internal Medicine, this idea that some of these things that we find when we take a look at the brain are really, I'm going to say, just sort of uncertain predictive value. And as more people are undergoing imaging, of course, we're starting to see these things a lot more often, incidentalomas. This is, in some respects, to me that's how it smacks.

These are two study populations, the Atherosclerosis Risk in Communities Study. That's one where there's MRI imaging data and up to five cognitive assessments over 20 years, and they used two of those studies. They looked at infarctions, areas in the brain where it was clear that there was an interruption in the blood supply, subsequent, what I'm going to call scarring, for lack of a better word, right? They had people characterized as having none, smaller ones only, or larger ones only -- those would be 3 to 20 millimeters -- or actually had both of those.

1,884 participants who came into this at about 62 years of age. Participants with both smaller and larger infarctions had steeper cognitive decline by more than half a standard deviation. That's a pretty powerful kind of predictor with regard to the cognitive risk. The smaller and the larger alone were not necessarily associated with anything. They still saw cognitive decline, but there was no real separation between those. Basically, adding to this idea that we can take a look at these findings and say, "Oops, you're at risk for cognitive decline." It's unclear to me what the action point is.

Rick: And our listeners should be aware is [that] we're talking about patients that did not have any clinical evidence of stroke. So Elizabeth, I agree with you. First of all, it's surprising to me that either small or large strokes independently weren't associated with a cognitive decline. I would have thought that if you find this in midlife, later in life you're going to have advanced cognitive decline.

And in a small number of patients, only 2% that had both small and large strokes, again, asymptomatic, they did have a much larger cognitive decline. The hypothesis is that's evidence of both big and small vessel disease. And either one of those, there's some resilience associated with it. But when you have both together, there's no wiggle room, and that's what results in increased cognitive decline.

Based upon that information, first of all, is it believable or not? It needs to be replicated in additional studies, in my opinion. But secondly is, what do you do with that information now and what do you tell that patient?

Elizabeth: I guess the other thing is the risk factors we're well aware of, high blood pressure and so on, that hopefully would already be being controlled for, so I'm not sure I agree with you [as to] what additional information or action points this points us toward.

Rick: You're right. If someone has diabetes or hypertension or high cholesterol, you're not going to say, "Their MRI scan looks normal so we're not going to treat the underlying cause." You're going to do that anyway.

Elizabeth: OK. Finally, in Annals, let's turn to a rather disturbing sequela of cannabis use.

Rick: This is synthetic cannabinoid use. It's unusual. This is actually a case report. We don't usually talk about case reports. We want larger studies. It's endemic of a little bit larger issue. In March of 2018, an outbreak of coagulopathy -- that is, thin blood -- occurred in Illinois after people smoked a synthetic cannabinoid. It was believed to be contaminated with a rodenticide. That rodenticide was like coumadin, but these new rodenticides are actually called super coumadins or super warfarins. These super warfarins' effects can last for months.

What this case report highlighted was a 26-year-old otherwise healthy woman who presented to the emergency department with bleeding of the gums and excessive bleeding with her menstrual periods as well. She had a 4-year history of smoking cannabinoids daily and she did that so that she didn't fail drug testing because the drug testing detects cannabis, but not cannabinoids.

What they found out was, sure enough, her blood was "thin," and they began to treat it with the routine measures. They gave her blood products to replace some of the coagulants and also gave her vitamin K, and it normalized. But then within a day and a half later, it rebounded. Again, her blood was excessively thin and they treated it again. Then at six days, it rebounded again.

They had to put her on high-dose vitamin K. In fact, it was high enough a dose of vitamin K that the local pharmacy couldn't provide it, so they had to keep her in the hospital for longer. And then, the cost was prohibitive as well for her to continue it, so she stopped it and 62 days after the initial report, she still has thin blood. I bring this to the attention of our listeners and health care providers is if you detect a coagulopathy in a person that has used synthetic cannabinoids, suspect a rodenticide. And if it needs to be treated, it may need to be treated for weeks and months.

Elizabeth: Has this case resolved?

Rick: It's hard to know because, as I mentioned to you, 2 months afterward she was reported to still have a coagulopathy, and the case reports notes that she was lost of followup after she moved out of state, so we don't have any particular followup on this specific patient.

Elizabeth: Certainly, we're seeing people right now. In fact, someone who did die as a result of vaping and some of the stuff that's in there -- lots of reports now going on about that. I guess I just have to say, "Gosh, smoking things, not a good idea, and smoking synthetic things, even a worse idea."

Rick: Elizabeth, I think that sums it up.

Elizabeth: On that note, then, that's a look at this week's medical headlines from Texas Tech. I'm Elizabeth Tracey.

Rick: And I'm Rick Lange. Y'all listen up and make healthy choices.