Welcome to the 1st Issue of Executive Brief
Welcome to the first edition of Cleveland Clinic Executive Brief, our new quarterly e-newsletter created to add to your Executive Health experience.
This newsletter is a collaboration involving our executive health practitioners at Cleveland Clinic Cleveland, Florida and Canada. We will address common questions posed by executives, discuss new advances in medical care, and provide tips for optimizing your health and well-being throughout the year.
We welcome your input and look forward to helping you enjoy long-lasting good health.
Richard Lang, MD, MPH
Multivitamins: To Take or Not to Take?
5 Multivitamin Take-Home Points
There are five take-home message from these studies on daily multivitamins:
- Nutritional deficits. Anyone who is malnourished or has a nutritional deficiency needs to take a multivitamin.
- Cardiovascular events. If you are a healthy adult, taking a multivitamin will not reduce your risk for cardiovascular events such as a heart attack or stroke.
- Not an insurance policy. Many physicians and patients consider taking a daily multivitamin a “nutritional insurance policy.” However, taking a multivitamin is no substitute for healthy lifestyle choices, such as eating healthy foods from a balanced diet. A balanced diet is low in added sugars, processed foods and saturated and trans fat, and rich in fruits, vegetables, whole grains, lean protein sources and low-fat dairy products. Exercising most days of the week, maintaining a body mass index close to 25 kg/m2, and being tobacco-free are other modifiable lifestyle behaviors that will lower your risk for cardiovascular disease and cancer.
- For men. Taking a multivitamin may reduce a man’s overall cancer risk, but not his risk for the most common male cancers: prostate, colon, and lung. Multivitamins will not reduce a man’s risk dying from cancer, either.
- For women. Taking a vitamin did not lower the overall mortality rate for women, and some supplements may actually increase a woman’s risk of death.
Many of our patients ask if they should take a multivitamin and ask if there are any health benefits. The Center for Disease Control and Prevention reported in April 2011 that multivitamins/multiminerals are the most commonly used dietary supplements, with approximately 40 percent of men and women reporting use. More than half of our Executive Health patients report taking a daily multivitamin.
But do they really help? Or are patients less likely to exercise and eat better because they are taking a pill they believe will help them?
In 2010, the U.S. Department of Agriculture and U.S. Department of Health and Human Services reported that there was no evidence to support the recommendation of a multivitamin/mineral supplement for the primary prevention of chronic disease in the general population. Yet consumers spent $27 billion dollars on supplements in 2009 — and that figure is likely higher today.
Long-awaited men's study results surprising
The long-awaited results of the only large-scale, randomized study of the long-term effects of a multivitamin in cardiovascular disease and cancer prevention — the Physicians’ Health Study II (PHS II) — are telling (see box below).
In PHS II, more than 14,500 male physicians, ages 50 and older, took either a multivitamin or a placebo for an average of 11.2 years. Those who took multivitamins fared no better than those who took placebo in avoiding heart attacks, strokes and cardiovascular-related deaths. This held true even for men with a history of cardiovascular disease.
However, using a multivitamin yielded a modest 8 percent reduction in overall cancer risk. Nearly 2,700 men developed cancer during PHS II. Those taking a multivitamin had a modest reduction in overall cancer risk — and the risk fell further for men with a history of cancer.
Unfortunately, taking a multivitamin did not reduce men’s risk of dying from cancer during the study. In addition, taking a daily multivitamin had no effect on reducing men’s risk for the most common male cancers, prostate cancer and colorectal cancer.
Women's study tracks mortality
The results of the Iowa Women’s Health Study were published in 2011. Taking dietary vitamin and mineral supplements did not reduce the total mortality rate in older women (average age, 61). In fact, taking additional supplements was associated with higher death rates. However, supplement users reported better diets, exercised more, smoked less and were better educated, which may explain the lack of benefit.
The most important thing to ask yourself is, “Am I doing everything possible to optimize my overall health before taking a multivitamin and/or supplement?” That is your best guarantee of future health. Always discuss the vitamins and supplements you are taking with your physician. Finally, ask which cancer screening procedures you need based on your age, gender, and family history.
Physicians' Health Study II (PHS II) at a Glance
|Nov. 7 and 14, 2012 JAMA (Journal of The American Medical Association)
||14,500 male physicians ages 50 and older
||11.2-year average follow-up
||Determine if multivitamins reduce men’s risks of cardiovascular events and cancer
||> 1,700 cardiovascular events, evenly distributed between placebo and multivitamin groups
||18.3/1,000 in placebo group vs. 17.0/1,000 in multivitamin group; 50% prostate cancers
Lung Cancer Screening with Low-Dose CT
Low-dose computed tomography (LDCT) takes X-rays of the body in cross-section with very small doses of radiation.
- LDCT reveals small spots (nodules) or benign or malignant growths in the lung better and more safely than chest X-rays.
- LDCT finds lung nodules in at least 25 percent of all people who are scanned
- Three or four out of 100 lung nodules found on LCDT are typically cancer
LDCT is best done at facilities that follow “best practices” for CT screening. Look for high-volume, high-quality lung cancer screening and treatment centers like Cleveland Clinic. If you have CLDT, you should not get chest X-rays for lung cancer screening.
Lung cancer is the most common cancer affecting both men and women in the United States. The American Cancer Society estimates that more than 228,000 new U.S. cases of lung cancer will be diagnosed and that approximately 159,000 people will die from the disease in 2013.
Lung cancer is by far the leading cause of cancer death among both men and women. The five-year survival rate is only 15 percent. More people die of lung cancer than of colon, breast and prostate cancers combined.
LCDT makes a difference
The earlier the stage of lung cancer at the time of diagnosis, the better the chance of survival. On Feb. 25, 2013, American Cancer Society researchers reported that screening appropriate former and current smokers with low-dose computed tomography (LDCT) can prevent up to 12,000 U.S. lung cancer deaths per year.
In 2010, the National Cancer Institute noted a statistically significant reduction in lung cancer mortality among high-risk adults screened with LCDT vs. chest X-ray for three consecutive years. Ongoing analysis of the National Lung Screening Trial data revealed that one out of five— 20 percent — of people who would otherwise die of lung cancer survived because of LDCT screening.
New screening guidelines
LDCT screening is not for everyone. The American Lung Association and the American Cancer Society published new lung cancer screening recommendations in January 2013. Active smokers will be advised to enter a smoking cessation program and, if they meet these criteria, to have LDCT screening:
- Age: Ages 55 to 74 with no signs or symptoms of lung cancer
- Smoking history: Active or former smokers with a 30 pack-year history (e.g., smoking one pack per day for 30 years or two packs per day for 15 years)
- Former smokers: Must have quit within the past 15 years
- General health exclusions: No life-limiting comorbid conditions, metallic implants or devices in the chest or back, or need for home oxygen supplementation
- Prior screenings: No chest CT within the past 12 months.
Check with your insurer
At this time, most insurers and Medicare do not cover the cost of lung cancer screening LDCT. Be sure to check with your insurance plan to see what is covered. Ask your doctor and the facility doing the CT scan to carefully and clearly explain all costs you may possibly incur, not just the cost of the CT scan alone. LDCT usually costs $300 to $500; the out-of-pocket cost for LDCT at Cleveland Clinic is $125.
For more information, visit www.clevelandclinic.org/lungcancerscreening
Or download a PDF from the American Lung Association.
Use Caution with Calcium Supplements
In 2011, the Institute of Medicine published recommendations on calcium and vitamin D dietary allowances for bone health. After reviewing more than 1,000 studies, the institute recommended:
- 1,000 mg of calcium for women ages 19 to 50 and for men ages 19 to 70 daily
- 1,200 mg of calcium daily for women over age 50 and men over age 70
- 600 IU of vitamin D daily for all adults ages 19 to 50
- 800 IU of vitamin D daily for all adults over age 50
- Blood levels of 20/ng/mL for 25-hyroxyvitamin D
The institute reported that the benefits for calcium and vitamin D for other health issues — such as heart disease, diabetes and cancer — were unclear.
Two new studies question supplements
Recently, the effectiveness of calcium and vitamin D in fracture prevention has come into question, along with the safety of calcium supplements.
In February 2013, the U.S. Preventive Services Task Force studied vitamin D and calcium supplementation in primary fracture prevention and:
- Decided more evidence is needed to balance the benefits and risks of combined vitamin D and calcium supplementation in premenopausal women and in men
- Recommended against daily supplementation of more than 400 IU of vitamin D and more than 1,000 mg of calcium in postmenopausal women (This does not apply to people who have a history of fractures, osteoporosis or vitamin D deficiency, or who live in nursing homes or similar facilities)
- Called for further research to determine whether more than 400 IU of vitamin D and more than 1,000 mg of calcium daily will reduce fractures in postmenopausal women and in older men
Calcium supplements questioned for men
The large, prospective National Institutes of Health-AARP Diet and Health Study, published in February 2013, followed more than 385,000 adults for a mean of 12 years. The men and women were ages 50 to 71.
Researchers assessed baseline levels of calcium from dietary sources and from supplements (calcium alone, multivitamins with calcium, calcium antacids). They then reviewed death rates from heart disease, stroke and other forms of cardiovascular disease.
Researchers found that:
- Men who took calcium supplements had a 20 percent higher risk of dying from cardiovascular disease, especially if they took 1,500 mg or more per day
- Women who took calcium supplements did not have increased mortality rates from cardiovascular disease
What we recommend
We advise the following for our patients:
- Review your dietary history with your physician and/or dietitian to determine if you are getting enough calcium. Most patients can achieve adequate calcium by eating calcium-rich diet foods.
- Look for dietary sources of calcium rather than supplements if you need more calcium. Excellent sources of calcium are low-fat milk and dairy products; a variety of seafood, such as canned fish with bones, like salmon and sardines; dark green leafy vegetables, such as kale, collards and broccoli; calcium-fortified orange juice; and breads made with calcium-fortified flour.
- If you are over age 50, Taking 800 to 1,000 IU of vitamin D daily should be sufficient to maintain a vitamin D blood level above 20 ng/mL. Taking vitamin D after your biggest meal of the day to increase absorption should result in higher blood levels.
- If you are overweight, you may need a higher daily dose to maintain blood levels above 20 ng/mL. Check with your physician if you need a vitamin D blood test.
Contact Cleveland Clinic Executive Health Program
Appointments: 800.223.2273, ext. 45707
Toronto, Ontario, Canada
Information and appointments: 416.507.6600 or 888.507.6885
Information and appointments: 954.659.5380 or 800.729.5258