doi:10.1017/S0007114512000098
Vitamin D3 and the risk of CVD in overweight and obese women: a
randomised controlled trial
Amin Salehpour1, Farzad Shidfar1*, Farhad Hosseinpanah2, Mohammadreza Vafa1, Maryam Razaghi1,
Anahita Hoshiarrad3 and Mahmoodreza Gohari4
1
British Journal of Nutrition
Department of Nutrition, School of Public Health, Tehran University of Medical Sciences, No. 52, Alvand Street,
Arjantin Square, Tehran, Iran
2
Obesity Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Floor
4th, Number 24, Parvaneh Street, Yemen Street, Chamran Exp, Tehran, Iran
3
National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, No. 42,
Arghavan Street, Farahzadi Boulevard, Shahrak-e Gharb, Tehran, Iran
4
Department of Biostatistics, Tehran University of Medical Sciences, No. 52, Alvand Street, Arjantin Square, Tehran, Iran
(Submitted 18 August 2011 – Final revision received 14 December 2011 – Accepted 5 January 2012 – First published online 9 February 2012)
Abstract
Evidence indicates that vitamin D deficiency contributes to CVD. We investigated the effect of vitamin D3 supplementation on cardiovascular risk factors in women. Healthy premenopausal overweight and obese women (n 77; mean age 38 (SD 8·1) years) were randomly
allocated to the vitamin D (25 mg/d as cholecalciferol) or the placebo group in a double-blind manner for 12 weeks. Blood pressure, serum
lipoproteins, apolipoproteins and anthropometric parameters were recorded. Dietary intake was recorded using 24 h food recall and FFQ.
Physical activity was assessed by the International Physical Activity Questionnaire. Mean total cholesterol concentrations increased in the
vitamin D group (0·08 (SD 0·56) mmol/l) but declined in the placebo group (0·47 (SD 0·58) mmol/l), and a significant effect was observed
(P#0·001). In the vitamin D group, mean HDL-cholesterol concentration increased, whereas it decreased in the placebo group (0·07 (SD
0·2) v. 20·03 (SD 0·2) mmol/l; P¼ 0·037). Mean apoA-I concentration increased in the vitamin D group, although it decreased in the placebo
group (0·04 (SD 0·39) v. 20·25 (SD 0·2) g/l; P# 0·001). Mean LDL-cholesterol:apoB-100 ratio augmented in the vitamin D group, while this
ratio declined in the placebo group (0·11 (SD 0·6) v. 2 0·19 (SD 0·3); P¼0·014). Body fat mass was significantly decreased in the vitamin D
group more than the placebo group (22·7 (SD 2) v. 20·4 (SD 2) kg; P# 0·001). The findings showed that supplementation with vitamin D3
can significantly improve HDL-cholesterol, apoA-I concentrations and LDL-cholesterol:apoB-100 ratio, which remained significant in the
multivariate model including anthropometric, dietary and physical activity measures.
Key words: Vitamin D: CVD: Obesity
Vitamin D is recognised as the vitamin of sunshine(1).
A relationship between vitamin D and CVD has been proposed by observing more incidence of CVD in winter compared with summer in many countries(2,3), which might be
attributable to the protective effect of vitamin D on CVD(4).
Ecological studies have indicated the higher rate of CHD
and high blood pressure increment with more distance from
the equator, which is also related to low sun exposure and
higher prevalence of vitamin D deficiency(5,6). It has been
shown that a range of markers including geographic latitude,
altitude and season affect vitamin D status which are negatively correlated with cardiovascular morbidity and mortality.
Evidence suggests that low levels of vitamin D may contribute
to the development of CVD(7).
On the other hand, a range of CVD risk factors including
dyslipoproteinaemia, high blood pressure, reduced glucose
tolerance, diabetes and increased inflammatory markers are
related to obesity, which has been increasing dramatically
during recent decades(8 – 10). Serum 25-hydroxyvitamin D
(25(OH)D) levels negatively correlate with BMI(11). It is
likely that alteration in vitamin D homeostasis affects
CVD development in obese individuals(12). Low levels of
25(OH)D cause higher levels of parathyroid hormone (PTH),
which is a known non-traditional CVD risk factor(13,14).
Investigations have shown that hypovitaminosis D has an
undesirable effect on total and LDL-cholesterol concentrations(15), therefore resulting in high total cholesterol and
low apoA-I concentrations. An independent and positive
Abbreviations: 25(OH)D, 25-hydroxyvitamin D; HR, hazard ratio; PTH, parathyroid hormone.
* Corresponding author: Dr F. Shidfar, fax þ98 21 88779487, email f-shidfar@tums.ac.ir
Downloaded from https://www.cambridge.org/core. IP address: 18.215.181.253, on 26 Nov 2021 at 03:04:08, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0007114512000098
British Journal of Nutrition (2012), 108, 1866–1873
q The Authors 2012
British Journal of Nutrition
significant correlation has been reported among serum
25(OH)D levels and apoA-I and HDL-cholesterol concentrations. It seems that the effects of vitamin D on the lipid profile are independent of Ca and other unfavourable effects
caused by high type 2 diabetes risk(15,16).
Scragg et al.(17) and Jorde et al.(18) have shown the association between 25(OH)D and blood pressure. Vitamin D affects
blood pressure via paracrine and endocrine mechanisms in
tissues that are specifically related to high blood pressure
including vascular smooth muscle cells(19), the endothelium
and cardiomyocytes(20). Also, 1,25-hydroxyvitamin D is considered as a negative endocrine regulator of the renin– angiotensin system, and sunlight exposure as an indirect marker of
vitamin D synthesis in the skin has an inverse correlation with
the prevalence of high blood pressure, reducing blood pressure levels(20 – 22).
As the prevalence of vitamin D deficiency is high in Iranian
women(23,24) and the burden of overweight and obesity is the
fifth leading risk for global deaths(25), which increases the risk
of non-communicable diseases including CVD, we evaluated
the effect of vitamin D3 supplementation on cardiovascular
risk factors in healthy overweight and obese women.
1867
patient used oral contraceptive pills and five other patients
were unwilling to continue the 12-week examination for personal reasons. Finally, seventy-seven participants completed
the study and, of these, thirty-nine were in the vitamin D
group and thirty-eight were in the placebo group.
Design
A vitamin D3 supplement (25 mg/d as cholecalciferol; Merck
Pharma GmbH) or placebo (25 mg/d as lactose; Merck
Pharma GmbH) was given to the participants per month.
The period of the intervention was 90 d and the participants
took one tablet of vitamin D3 supplement or placebo every
day. Compliance with the supplementation was 87 %.
Blood samples were collected from the antecubital vein of
each patient after an overnight fast of at least 12 h. After centrifugation for 20 min (3000 g), the serum samples were frozen
simultaneously and stored at 2808C until analysed. In order to
eliminate the probable effects of sex hormones on blood
lipids, blood sampling was not performed between days 1
and 5 of the menstrual cycle.
Anthropometry measurements
Materials and methods
Participants
The present study was performed between November 2009
and April 2010 in the Heart and Vascular Laboratory at the
Pharmacology Department of Tehran University of Medical
Sciences, Tehran, Iran. We distributed advertisements in the
campus and requested all women to participate in the study.
The inclusion criteria were as follows: good public health
status; age 18 – 50 years; BMI $ 25 kg/m2; free of known
osteoporosis; gastrointestinal disease; diabetes mellitus; CVD;
renal disease; high blood pressure (. 160/90 mmHg). Participants were excluded from the study if they were following a
weight-reduction programme, taking weight-loss drugs,
having a change in weight more than 3 kg during the last 3
months, pregnant, lactating, smoking, drinking alcohol,
taking nutritional supplements, cholesterol and TAG-lowering
agents as well as anti-hypertensive agents. At the beginning of
the study, sunscreen use was discontinued in all subjects.
A total of eighty-five participants who met the above
inclusion criteria were recruited into a double-blind clinical
trial. We randomly assigned participants to one of two groups:
vitamin D (n 42) or placebo (n 43). Written informed consent
was obtained from all subjects. The study was conducted
according to the guidelines laid down in the Declaration of
Helsinki and all procedures involving human subjects/patients
were approved by the Ethics Committee of the Tehran University of Medical Sciences and Iranian Registry of Clinical Trial
(registration no. IRCT138809092709N2). This trial was registered at ClinicalTrials.gov as NCT01344161. Of the eighty-five
participants who were eligible for the present intervention
study, eight subjects dropped out of the follow-up: in the
vitamin D group, one patient became pregnant and one patient
followed a weight-loss programme. In the placebo group, one
Body weight and height were measured on a digital scale
(model 763; Seca GmbH & Co, KG) with participants wearing
light indoor clothing. Waist and hip circumference were
measured using an Ergonomic Circumference Measuring
Tape (model 201; Seca GmbH & Co, KG). BMI was calculated
by dividing weight (kg) by height (m2). Body composition was
assessed by Bioelectrical Impedance Analysis (model 4000,
Body Stat Quad Scan; Bodystat). All anthropometric indices
were measured by following the WHO standard procedures(26). We assessed physical activity levels using the
International Physical Activity Questionnaire(27) and determined the average of metabolic equivalents (MET)-min/week.
Dietary assessments
Energy, macronutrient, Ca, vitamin D, saturated fat, MUFA and
PUFA intakes were estimated using 24 h food recall and validated FFQ(28). On a monthly basis, a nutritionist completed
the questionnaires by a direct interview. Because the Iranian
food composition table is incomplete (limited to only raw
materials and a few nutrients)(29), each food and beverage,
only unfortified US food equivalents, was analysed for nutrient
intake using Nutritionist IV software (version 4.1; First Databank Division, The Hearst Corporation) to assess macronutrient and micronutrient contents of the foods. The Iranian food
composition table was used as an alternative for traditional
Iranian food items, such as kashk, which is not included in
the Food Composition Tables for Use (United States Department of Agriculture food composition table)(30).
Blood pressure
Systolic and diastolic blood pressure was measured in the
right or the left arm supported at the heart level of seated
Downloaded from https://www.cambridge.org/core. IP address: 18.215.181.253, on 26 Nov 2021 at 03:04:08, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0007114512000098
Vitamin D3 supplementation and risk of CVD
A. Salehpour et al.
participants (Model Gamma G-7; Heine). Means of two
measurements taken at 5 and 10 min of rest were used.
6·6 and 7·8 %, respectively. Also, we measured apoA-I and
apoB-100 using a sandwich technique (ELISA; AlerCHEK).
Intra- and inter-assay CV for apoA-I and apoB-100 were 5·6,
6·9 % and 6·1, 7·4 %, respectively.
Biochemical assay
British Journal of Nutrition
25(OH)D was measured using an enzyme immunoassay
(Immunodiagnostic Systems Limited). Intra- and inter-assay
CV for 25(OH)D were 6·9 and 8·1 %, respectively. Intact PTH
was measured using an immunoenzymometric assay (Immunodiagnostic Systems Limited). Intra- and inter-assay CV for
intact PTH were 5·5 and 8·3 %, respectively. TAG, total cholesterol, LDL-cholesterol and HDL-cholesterol were measured by
a direct colorimetric enzymatic method (Greiner). Intra- and
inter-assay CV for TAG were 2·6 and 2·9 %, for total cholesterol
were 1·4 and 2·1 %, for LDL-cholesterol were 2·2 and 2·5 %,
and for HDL-cholesterol were 2·4 and 2·6 %, respectively.
Lipoprotein(a) was measured by an enzyme immunoassay
(Mercodia). Intra- and inter-assay CV for lipoprotein(a) were
Statistical analysis
Continuous variables are expressed as means and standard
deviations, and categorical variables as percentage proportions. The change in variables was analysed with ANCOVA to
adjust mean differences in variables, in which baseline value,
fat mass and waist circumference were used as covariates.
P values ,0·05 were considered statistically significant.
Relationships between change in 25(OH)D concentrations and
cardiovascular markers were evaluated using simple
Pearson’s correlations. To adjust the analyses for confounding
variables, partial correlations were computed for all dependent
variables, after adjusting for fat mass and waist circumference
Table 1. Baseline characteristics of the participants who received vitamin D3 supplements (25 mg/d) or placebo*
(Mean values and standard deviations)
Vitamin D group
Placebo group
Characteristics
Mean
SD
Mean
SD
Age (years)
Body weight (kg)
BMI (kg/m2)
Fat mass (kg)
Waist circumference (cm)
Physical activity (MET-min/week)
Energy intake
kcal/d
kJ/d
Carbohydrate intake (g/d)
Fibre intake (g/d)
Protein intake (g/d)
Fat intake (g/d)
Dietary Ca intake (mg/d)
Dietary vitamin D intake (mg/d)
Dietary SFA intake (g/d)
Dietary MUFA intake (g/d)
Dietary PUFA intake (g/d)
Systolic blood pressure (mmHg)
Diastolic blood pressure (mmHg)
25(OH)D (nmol/l)‡
PTH (pmol/l)‡
TAG (mmol/l)
Total cholesterol (mmol/l)
LDL-C (mmol/l)
HDL-C (mmol/l)
ApoA-I (g/l)
ApoB-100 (g/l)
TAG:HDL-C
Total cholesterol:HDL-C
Total cholesterol:LDL-C
LDL-C:HDL-C
LDL-C:apoB-100
ApoA-I:apoB-100
Lipoprotein(a) (mmol/l)
38†
73·9
30·1
30·2
89·9
902
7
10·2
3·9
6·9
8·7
1245
37
75·1
29·5
29
91·2
702
8
11·9
4·4
8·7
12·1
996
1866
7807
280
16
64
55
873
0·53
18·8
19·2
13
110·5
67·9
36·8
1·4
1·51
4·71
3·1
0·91
1·63
1·35
1·78
5·45
1·54
3·64
2·34
1·26
0·62
927
3878
134
9
29
44
586
0·6
15·4
18·5
17·1
17·5
10·1
30
0·7
0·4
0·6
0·59
0·2
0·2
0·2
0·6
1·5
0·14
1·2
0·5
0·3
0·62
2060
8619
329
18
76
49
677
0·39
15·8
16·7
12·2
116·7
71·9
46·9
1·4
1·62
4·89
3·2
0·87
1·78
1·38
2·0
5·88
1·52
3·96
2·39
1·33
0·56
834
3489
140
10
35
24
386
0·37
9·1
9·5
7·8
11·4
9·1
32
0·7
0·5
0·8
0·77
0·2
0·2
0·2
0·98
1·7
0·14
1·3
0·5
0·2
0·52
P
0·29
0·61
0·54
0·53
0·59
0·43
0·33
0·12
0·23
0·10
0·43
0·08
0·22
0·30
0·45
0·78
0·07
0·07
0·15
0·84
0·31
0·29
0·28
0·45
0·006
0·53
0·25
0·25
0·59
0·28
0·68
0·36
0·62
MET, metabolic equivalents; 25(OH)D, 25-hydroxyvitamin D; PTH, parathyroid hormone; LDL-C, LDL-cholesterol; HDL-C,
HDL-cholesterol.
* Mean values were not significantly different from week 0 between the groups (P.0·05; unpaired t test).
† Mean values were not significantly different from month 0 between the groups (P.0·05; unpaired t test).
‡ To convert 25(OH)D values to ng/ml, divide by 2·5. To convert PTH values to pg/ml, divide by 0·11.
Downloaded from https://www.cambridge.org/core. IP address: 18.215.181.253, on 26 Nov 2021 at 03:04:08, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0007114512000098
1868
as independent variables. The statistical program SPSS
(version 16; SPSS, Inc.) was used to perform the analyses.
Results
British Journal of Nutrition
Participant characteristics are shown in Table 1. Baseline
physical characteristics in both groups were similar. The
intake of SFA and MUFA decreased in both groups from the
beginning of the study up to week 12. The intake of PUFA
increased in the vitamin D group and decreased in the placebo group. Despite this, changes in dietary fatty acid intake
were not significant between the two groups.
Baseline systolic blood pressure was lower in the intervention group (67·9 (SD 10·1) v. 71·9 (SD 9·1) mmHg). Systolic
blood pressure increased in the vitamin D group, but declined
in the placebo group (0·51 (SD 12·7) v. 2 2·2 (SD 10·2) mmHg;
Table 2). Diastolic blood pressure increased in both groups
1869
(2·3 (SD 6·7) v. 0·13 (SD 8·3) mmHg). The changes were not
statistically significant between the two groups.
At baseline, the percentage of subjects with hypovitaminosis
D (25(OH)D , 75 nmol/l) and vitamin D sufficiency (25(OH)D
$ 75 nmol/l) in the vitamin D group was 89·7 and 10·3 %,
reaching 53·8 and 46·2 % after supplementation, respectively.
Related values in the placebo group were 89·5 and 10·5 % at
baseline, reaching 86·8 and 13·2 %, respectively (P, 0·001).
Serum intact PTH concentrations declined in the vitamin D
group up to 1·2 (SD 0·5) pmol/l. However, serum PTH concentrations increased in the placebo group up to 1·7 (SD
0·8) pmol/l during 12 weeks (P,0·001). Body fat mass
decreased in the vitamin D and placebo groups (22·7 (SD 2)
v. 2 0·4 (SD 2) kg; P, 0·001, respectively).
Serum TAG concentrations decreased in both groups after
12 weeks, but these alterations were higher in the placebo
group compared with in the vitamin D group (0·26 (SD 0·28)
v. 0·29 (SD 0·3) mmol/l, respectively). This result was not
Table 2. Anthropometric, dietary and biochemical variables in the participants who received vitamin D3 supplements (25 mg/d) or placebo
after the intervention and change in variables between the measurement periods
(Mean values and standard deviations)
Vitamin D group
Week 12
Placebo group
Change*
Week 12
Change
Characteristics
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Body weight (kg)
BMI (kg/m2)
Fat mass (kg)
Waist circumference (cm)
Physical activity (MET-min/week)
Energy intake
kcal/d
kJ/d
Carbohydrate intake (g/d)
Fibre intake (g/d)
Protein intake (g/d)
Fat intake (g/d)
Dietary Ca intake (mg/d)
Dietary vitamin D intake (mg/d)
Dietary SFA intake (g/d)
Dietary MUFA intake (g/d)
Dietary PUFA intake (g/d)
Systolic blood pressure (mmHg)
Diastolic blood pressure (mmHg)
25-Hydroxyvitamin D (nmol/l)
PTH (pmol/l)
TAG (mmol/l)
Total cholesterol (mmol/l)
LDL-C (mmol/l)
HDL-C (mmol/l)
ApoA-I (g/l)
ApoB-100 (g/l)
TAG:HDL-C
Total cholestrol:HDL-C
Total cholestrol:LDL-C
LDL-C:HDL-C
LDL-C:apoB-100
ApoA-I:apoB-100
Lipoprotein(a) (mmol/l)
73·5
30
28·2
89·5
892
10·4
4
7·5
8·8
1488
2 0·3
2 0·13
2 2·7
2 0·3
2 10
1·5
0·6
2
4·3
1627
75
29·5
28·6
91·6
1081
12·3
4·6
8·9
13
1372
2 0·1
2 0·04
2 0·4
0·4
379
1·7
0·6
2
4·1
1137
2010
8409
312
16
72
53
829
0·4
18·1
16·8
13·7
111
70·2
75
1·2
1·25
4·79
3·2
0·99
1·67
1·31
1·3
4·94
1·51
3·34
2·45
1·3
0·66
1289
5393
186
12
53
43
533
0·47
12·3
13·2
16·7
11·3
8·8
22
0·5
0·36
0·8
0·79
0·1
0·2
0·2
0·4
1·0
0·15
0·9
0·4
0·3
0·63
143·7
601
31·84
1
7·8
2 2·3
2 43·9
2 0·09
2 0·67
2 2·3
0·67
0·51
2·3
38·2
2 0·2
2 0·26
0·08
0·13
0·07
0·04
2 0·03
2 0·48
2 0·51
2 0·02
2 0·29
0·11
0·04
0·03
1358·4
5683
194·6
11·7
54·3
52·2
674·4
0·77
16·3
18·2
23·2
12·7
6·7
32
0·5
0·28
0·56
0·5
0·2
0·39
0·2
0·5
1·2
0·15
1
0·6
0·3
0·19
1852
7748
294
14
66
45
625
0·37
13·9
15·2
11·9
114·4
72·1
51·5
1·7
1·32
4·41
2·9
0·84
1·53
1·34
1·64
5·33
1·51
3·58
2·2
1·16
0·61
992
4150
164
7
32
36
454
0·35
11·4
18·2
8·4
13
10·6
31
0·8
0·4
0·8
0·75
0·1
0·2
0·2
0·8
1·1
0·13
0·9
0·4
0·2
0·55
2 208
2 870
2 34·32
2 4·3
2 9·3
2 4·2
2 51·8
2 0·04
2 1·8
2 1·4
2 0·31
2 2·2
0·13
4·6
0·2
2 0·29
2 0·47
2 0·3
2 0·03
2 0·25
2 0·03
2 0·36
2 0·55
2 0·005
2 0·38
2 0·19
2 0·17
0·05
920·9
3853
143
11·3
35·6
39·3
509·5
0·52
13·4
20·1
10
10·2
8·3
14
0·5
0·3
0·58
0·5
0·2
0·2
0·1
0·5
1·2
0·13
1
0·3
0·3
0·1
MET, metabolic equivalents; PTH, parathyroid hormone; LDL-C, LDL-cholesterol; HDL-C, HDL-cholesterol.
* After 12 weeks.
† An ANCOVA was used to adjust mean differences in all dependent variables.
‡ Mean values remained significantly different between the groups after adjusting for fat mass and waist circumference (P, 0·05).
P†
0·71
0·5
, 0·001
0·38
0·23
0·32
0·23
0·1
0·29
0·48
0·18
0·7
0·73
0·83
0·81
0·3
0·207
, 0·001
, 0·001‡
0·588
, 0·001‡
, 0·001
0·037‡
, 0·001‡
0·942
0·356
0·902
0·531
0·718
0·014‡
0·009‡
0·557
Downloaded from https://www.cambridge.org/core. IP address: 18.215.181.253, on 26 Nov 2021 at 03:04:08, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0007114512000098
Vitamin D3 supplementation and risk of CVD
150·00
150·00
Changes in 25(OH)D concentrations (nmol/l)
statistically significant. Baseline serum total cholesterol
concentrations in the vitamin D group were lower than those
in the placebo group (4·7 (SD 0·6) v. 4·89 (SD 0·8) mmol/l,
respectively). After 12 weeks, total cholesterol concentrations
increased in the vitamin D group and declined in the placebo
group (0·08 (SD 0·56) v. 2 0·47 (SD 0·58) mmol/l; P,0·001),
respectively. Similarly, serum LDL-cholesterol concentrations
increased in the vitamin D group and decreased in the
placebo group (0·13 (SD 0·5) v. 2 0·3 (SD 0·5) mmol/l;
P, 0·001), respectively. HDL-cholesterol concentrations
increased in the vitamin D group and declined in the placebo
group (0·07 (SD 0·2) v. 2 0·03 (SD 0·2) mmol/l; P¼0·037),
respectively. At baseline, serum apoA-I concentrations in
the vitamin D group were lower than those in the
placebo group (1·63 (SD 0·2) v. 1·78 (SD 0·2) g/l; P¼ 0·006),
respectively. After the intervention, apoA-I concentration
increased in the vitamin D group, though it decreased in the placebo group (0·04 (SD 0·39) v. 20·25 (SD 0·2) g/l; P, 0·001).
Serum apoB-100 concentrations declined in both groups,
but the changes were not statistically significant. The LDLcholesterol:apoB-100 ratio increased in the vitamin D group,
which indicates less atherogenic properties of LDL-cholesterol
particles, whereas this ratio declined in the placebo group
indicating that LDL-cholesterol particles were smaller and
had higher density (0·11 (SD 0·6) v. 20·19 (SD 0·3); P¼0·014).
The apoA-I:apoB-100 ratio increased in the vitamin D group,
but decreased in the placebo group (0·04 (SD 0·3) v. 20·17
(SD 0·3); P¼0·009).
A positive correlation was observed between changes in
serum 25(OH)D concentrations and systolic blood pressure
(r 0·24, P¼0·032), which remained statistically significant
after adjusting for fat mass and waist circumference (r 0·23,
P¼ 0·044). A positive and significant trend was seen
between changes in serum 25(OH)D concentrations and
Changes in 25(OH)D concentrations (nmol/l)
British Journal of Nutrition
A. Salehpour et al.
100·00
50·00
0·00
–50·00
–100·00
–0·75
–0·50
–0·25
0·00
0·25
0·50
Changes in HDL-C concentrations (mmol/l)
Fig. 2. Relationship between changes in serum 25-hydroxyvitamin D
(25(OH)D) and HDL-cholesterol (HDL-C) concentrations. W, Vitamin D group;
X, placebo group. r 0·260; P¼ 0·022.
total cholesterol concentrations (r 0·27, P¼0·014; Fig. 1),
which did not remain significant after adjusting for fat mass
and waist circumference. There was a positive and significant
correlation between changes in serum 25(OH)D concentrations and HDL-cholesterol concentrations (r 0·26,
P¼0·022; Fig. 2) and between serum 25(OH)D concentrations
and apoA-I concentrations (r 0·25, P¼ 0·023; Fig. 3). The correlation between changes in serum 25(OH)D concentrations
and HDL-cholesterol concentrations was statistically significant even after adjusting for fat mass and waist circumference
(r 0·25, P¼ 0·03), but did not remain significant between
changes in serum 25(OH)D concentrations and apoA-I
concentrations.
100·00
Discussion
50·00
0·00
–50·00
–100·00
–2·00
–1·00
0·00
1·00
Changes in total cholesterol concentrations
(mmol/l)
Fig. 1. Relationship between changes in serum 25-hydroxyvitamin D
(25(OH)D) and total cholesterol concentrations. W, Vitamin D group; X,
placebo group. r 0·279; P¼ 0·014.
The present study is one of the first reports about the
effect of vitamin D3 supplementation solely on blood lipids
and lipoproteins in healthy overweight and obese women.
The present study has shown that although the daily intake
of a 25 mg vitamin D3 supplement increases total and
LDL-cholesterol concentrations, it has a beneficial effect on
HDL-cholesterol, apoA-I concentrations, apoA-I:apo B-100
and LDL-cholesterol:apoB-100 ratios in overweight and
obese women.
In the present study, although vitamin D3 supplementation
significantly increased 25(OH)D concentrations, some participants in the vitamin D group did not reach sufficient 25(OH)D
concentrations. It seems that they may need higher doses or a
longer period of time to be supplemented(31). 25(OH)D concentrations are known to be an independent predictor of
CVD(32). 25(OH)D levels ,37·5 nmol/l, compared with levels
higher than 75 – 100 nmol/l, are related to an increase in
Downloaded from https://www.cambridge.org/core. IP address: 18.215.181.253, on 26 Nov 2021 at 03:04:08, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0007114512000098
1870
Changes in 25(OH)D concentrations (nmol/l)
150·00
100·00
50·00
0·00
–50·00
–100·00
British Journal of Nutrition
–1·00
–0·50
0·00
0·50
1·00
Changes in apoA-I concentrations (g/l)
Fig. 3. Relationship between changes in serum 25-hydroxyvitamin D
(25(OH)D) and apoA-I concentrations. W, Vitamin D group; X, placebo
group. r 0·25; P¼0·023.
cardiovascular events. In a previous study, men with 25(OH)D
levels #37·5 nmol/l had a higher risk of myocardial infarction
(R 2 2·42), compared with those with 25(OH)D levels
$ 75 nmol/l(33). Moreover, in a prospective cohort study with
an average follow-up duration of 7·7 years in 3285 patients,
Dobnig et al.(34) reported that hazard ratios (HR) for all-cause
mortality (HR 2·08, 95 % CI 1·60, 2·70; HR 1·53, 95 % CI 1·17,
2·01, respectively) and those for cardiovascular mortality
causes (HR 2·22, 95 % CI 1·57, 3·13; HR 1·82, 95 % CI 1·29,
2·58, respectively) in the two lowest quartiles of 25(OH)D
with medians of 19 and 33·2 nmol/l were higher compared
with patients in the highest quartiles of 25(OH)D with a
median of 71 nmol/l. In the Framingham Offspring Cohort
Study with an average follow-up duration of 5·4 years in individuals with high blood pressure, the risk of cardiovascular
events increased two times in participants with 25(OH)D concentrations # 37·5 nmol/l compared with those with 25(OH)D
concentrations $37·5 nmol/l(35). Scragg et al. reported that
among white patients without high blood pressure from the
Third National Health and Nutrition Examination Survey
(NHANES III 1988– 1994), systolic blood pressure and pulse
pressure values in the highest quartile of 25(OH)D
($85·7 nmol/l) were lowered by 1·8 and 1·6 mmHg, respectively, compared with the lowest quartile of 25(OH)D
(#40·4 nmol/l). Also, systolic blood pressure was decreased
up to 1·8 and 4·6 mmHg in patients aged . 50 and ,50
years, respectively, when 25(OH)D concentrations increased
from 20 to 100 nmol/l(17). In contrast, in a cross-sectional
study, the Longitudinal Aging Study Amsterdam, by Snijder
et al.(36), no correlation has been reported between
25(OH)D concentrations and systolic blood pressure or diastolic blood pressure. We did not find any significant change
in blood pressure after 12 weeks. Zittermann et al.(37) demonstrated that after 12 months of supplementation with 83 mg
1871
vitamin D/d coupled with a weight-reduction programme in
overweight patients, systolic and diastolic blood pressure
decreased, but only significant effects of time were observed.
Additionally, Major et al.(38) and Pfeifer et al.(39) reported similar results. PTH and its related peptides can affect cardiovascular cells via receptors(40 – 42). PTH is known as a risk factor for
CVD, and patients with hyperparathyroidism are more
exposed to cardiovascular morbidity and mortality(43,44). PTH
enhances myocyte hypertrophy(45) and vascular remodelling(46). Moreover, PTH probably has a pre-inflammatory
effect by stimulating cytokine release in vascular smooth
muscle cells(47). In the present study, PTH concentrations
decreased significantly in the vitamin D group, but increased
in the placebo group.
On the other hand, the correlation between vitamin D and
serum TAG concentrations has been reported in patients
with the end stage of renal disease(48). Zittermann et al.(37)
and Major et al.(38) demonstrated that TAG concentrations
reduced in the vitamin D group. It has been suggested that vitamin D can reduce hepatic TAG synthesis or secretion by
increasing intestinal Ca absorption(49). By this way, vitamin D
increases lipolytic activity of heparin and also increases TAG
uptake by peripheral tissues(50). Furthermore, Ca increment
in hepatocytes stimulates microsomal TAG transfer protein,
which is correlated with VLDL-cholesterol synthesis and
secretion. Vitamin D induces intestinal Ca absorption that
results in the suppression of Ca increment in hepatocytes and
a decrease in VLDL-cholesterol synthesis and/or secretion(49).
In the present study, supplementation with vitamin D3
increased total and LDL-cholesterol concentrations. Chiu et al.(51)
reported that 25(OH)D levels had a positive correlation with
total and LDL-cholesterol concentrations. Zittermann et al.(37)
also found a significant vitamin D-dependent increase in
LDL-cholesterol. In contrast, in 170 British Bangladeshis,
John et al.(52) reported a negative correlation between
25(OH)D concentrations and total and LDL-cholesterol concentrations. It seems that vitamin D through an increase in
intestinal Ca absorption(53) reduces the formation of insoluble
Ca – fat soaps(54), therefore resulting in low Ca in lumen content, a low rate of Ca bonding to bile acids(55,56), conversion
of cholesterol to bile acids and, finally, cholesterol
excretion(57). Several studies have demonstrated that serum
25(OH)D concentrations are a strong, independent predictor
of apoA-I concentrations(51,58,59). Auwerx et al.(59) reported
that apoA-I concentrations had a positive correlation with
25(OH)D levels in Belgian men. It has been postulated that
in the promoter of the apoA-I gene, there are vitamin D
response elements through which 1,25(OH)2D enhances the
transcription of the apoA-I gene in human hepatoma cells(60).
In conclusion, daily supplementation with 25 mg vitamin D3
by repletion of the body’s vitamin D storage results in significant improvement in some cardiovascular risk factors in overweight and obese women.
Acknowledgements
The authors thank Sahar Dehghani, Ghazaleh Shimi, Saeedeh
Nasiri and Majid Goharinejad for the anthropometric, dietary
Downloaded from https://www.cambridge.org/core. IP address: 18.215.181.253, on 26 Nov 2021 at 03:04:08, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0007114512000098
Vitamin D3 supplementation and risk of CVD
A. Salehpour et al.
British Journal of Nutrition
and specimen processing. Dr Mehdi Hedayati and colleagues
are acknowledged for the biochemical analyses. The study
was supported financially by the Tehran University of Medical
Sciences (grant no. 852) and the Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences
(grant no. 293). The authors’ contributions are as follows: A. S.
and M. R. contributed to the study design, data collection, data
interpretation and writing of the manuscript; F. S. and F. H.
contributed to the study design, recruitment of patients, data
collection, review of the original data and their compilation;
M. V. contributed to the study design, critical revision of the
manuscript for important intellectual content, and final
approval of the manuscript; A. H. contributed to the data analysis and interpretation, and critical revision of the manuscript
for important intellectual content; M. G. contributed to
the data analysis, manuscript revision, and critical revision
of the manuscript for important intellectual content. None of
the authors has any conflict of interest to declare.
15.
16.
17.
18.
19.
20.
21.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Holick M (1989) Phylogenetic and evolutionary aspects of
vitamin D from phytoplankton to humans. In Vertebrate
Endocrinology: Fundamentals and Biomedical Implications
[P Schreibman and M Pang, editors]. San Diego: Academic
Press.
Holick MF (2003) Vitamin D: a millennium perspective. J Cell
Biochem 88, 296 – 307.
Dunnigan MG, Harland WA & Fyfe T (1970) Seasonal
incidence and mortality of ischemic heart disease. Lancet
ii, 793 – 797.
Bull GM & Morton J (1975) Seasonal and short-term
relationships of temperature with deaths from myocardial
and cerebral infarction. Age Ageing 4, 19– 31.
Scragg R (1981) Seasonality of cardiovascular disease
mortality and the possible protective effect of ultraviolet
radiation. Int J Epidemiol 10, 337 – 341.
Grimes DS, Hindle E & Dyer T (1996) Sunlight, cholesterol
and coronary heart disease. QJM 89, 579 – 589.
Rostand SG (1997) Ultraviolet light may contribute to geographic and racial blood pressure differences. Hypertension
30, 150 – 156.
Zittermann A, Schleithoff SS & Koerfer R (2005) Putting
cardiovascular disease and vitamin D insufficiency into
perspective. Br J Nutr 94, 483 – 492.
Caballero B (2007) The global epidemic of obesity: an overview. Epidemiol Rev 29, 1– 5.
Bray GA & Bellanger T (2006) Epidemiology, trends,
and morbidities of obesity and the metabolic syndrome.
Endocrine 29, 109 – 117.
Sarti C & Gallagher J (2006) The metabolic syndrome: prevalence, CHD risk, and treatment. J Diabetes Complications 20,
121 –132.
Parikh SJ, Edelman M, Uwaifo GI, et al. (2004) The relationship between obesity and serum 1,25-dihydroxy vitamin D
concentrations in healthy adults. J Clin Endocrinol Metab
89, 1196 –1199.
Wilson PW, Kannel WB, Silbershatz H, et al. (1999) Clustering of metabolic factors and coronary heart disease. Arch
Intern Med 159, 1104– 1109.
Krause R, Buhring M, Hopfenmuller W, et al. (1998)
Ultraviolet B and blood pressure. Lancet 352, 709 – 710.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
Merke J, Hofmann W, Goldschmidt D, et al. (1987) Demonstration of 1,25(OH)2 vitamin D3 receptors and actions in
vascular smooth muscle cells in vitro. Calcif Tissue Int 41,
112 – 114.
Merke J, Milde P, Lewicka S, et al. (1989) Identification and
regulation of 1,25-dihydroxyvitamin D3 receptor activity
and biosynthesis of 1,25-dihydroxyvitamin D3: studies in
cultured bovine aortic endothelial cells and human dermal
capillaries. J Clin Invest 83, 1903 – 1915.
Scragg R, Sowers M & Bell C (2007) Serum 25-hydroxyvitamin D, ethnicity, and blood pressure in the Third National
Health and Nutrition Examination Survey. Am J Hypertens
20, 713 – 719.
Jorde R, Figenschau Y, Emaus N, et al. (2010) Serum
25-hydroxyvitamin D levels are strongly related to systolic
blood pressure but do not predict future hypertension.
Hypertension 55, 792 –798.
Holick MF (2006) High prevalence of vitamin D inadequacy
and implications for health. Mayo Clin Proc 81, 353 – 373.
Li YC, Kong J, Wei M, et al. (2002) 1,25-Dihydroxyvitamin D
(3) is a negative endocrine regulator of the renin-angiotensin
system. J Clin Invest 110, 229 –238.
Rostand SG & Drueke TB (1999) Parathyroid hormone,
vitamin D, and cardiovascular disease in chronic renal
failure. Kidney Int 56, 383 – 392.
Sambrook PN, Chen JS, March LM, et al. (2004) Serum
parathyroid hormone is associated with increased mortality
independent of 25-hydroxy vitamin D status, bone mass
and renal function in the frail and very old: a cohort study.
J Clin Endocrinol Metab 89, 5477– 5481.
Hashemipour S, Larijani B, Adibi H, et al. (2004) Vitamin D
deficiency and causative factors in the population of
Tehran. BMC Public Health 4, 38– 44.
Heshmat R, Mohammad K, Majdzadeh SR, et al. (2008)
A multi-center study among different urban areas. Iranian
J Publ Health 1, Suppl., 72 –78.
World Health Organization (2011) Obesity and Overweight.
Fact Sheet no. 311. www.who.int/mediacentre/factsheets/
fs311/en/ (updated February 2011).
World Health Organization (1995) Physical Status: The Use
and Interpretation of Anthropometry. Technical Report
Series no. 854. Geneva: WHO.
Craig CL, Marshall AL, Sjostrom M, et al. (2003) International
physical activity questionnaire: 12-country reliability and
validity. Med Sci Sports Exerc 35, 1381 – 1395.
Esfahani FH, Asghari G, Mirmiran P, et al. (2010) Reproducibility and relative validity of food group intake in a food frequency questionnaire developed for the Tehran Lipid and
Glucose Study. J Epidemiol 20, 150 – 158.
Azar M & Sarkisian E (1980) Food Composition Table of
Iran. Tehran: National Nutrition and Food Research Institute,
Shaheed Beheshti University.
United States Department of Agriculture, Agriculture of
Research Service (2009) Nutrient Data Laboratory Homepage.
www.nal.usda.gov/fnic/foodcomp/ (updated 27 April 2009).
Aloia JF, Patel M, Dimaano R, et al. (2008) Vitamin D intake
to attain a desired serum 25 hydroxyvitamin D concentration. Am J Clin Nutr 87, 1952– 1958.
Tishkoff DX, Nibbelink KA, Holmberg KH, et al. (2008)
Functional vitamin D receptor (VDR) in the t-tubules of cardiac myocytes: VDR knockout cardiomyocyte contractility.
Endocrinology 149, 558 – 564.
Giovannucci E, Liu Y, Hollis BW, et al. (2008) 25-Hydroxyvitamin D and risk of myocardial infarction in men: a prospective study. Arch Intern Med 168, 1174 –1180.
Downloaded from https://www.cambridge.org/core. IP address: 18.215.181.253, on 26 Nov 2021 at 03:04:08, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0007114512000098
1872
34.
35.
36.
37.
38.
British Journal of Nutrition
39.
40.
41.
42.
43.
44.
45.
46.
Dobnig H, Pilz S, Scharnagl H, et al. (2008) Independent
association of low serum 25-hydroxyvitamin D and
1,25-dihydroxyvitamin D levels with all-cause and cardiovascular mortality. Arch Intern Med 168, 1340 – 1349.
Wang TJ, Pencina MJ, Booth SL, et al. (2008) Vitamin D
deficiency and risk of cardiovascular disease. Circulation
117, 503 – 511.
Snijder MB, Lips P, Seidell JC, et al. (2007) Vitamin D status
and parathyroid hormone levels in relation to blood pressure: a population-based study in older men and women.
J Intern Med 261, 558 – 565.
Zittermann A, Frisch S, Berthold HK, et al. (2009) Vitamin D
supplementation enhances the beneficial effects of weight
loss on cardiovascular disease risk markers. Am J Clin Nutr
89, 1321 –1327.
Major GC, Alarie F, Doré J, et al. (2007) Supplementation
with calcium þ vitamin D enhances the beneficial effect of
weight loss on plasma lipid and lipoprotein concentrations.
Am J Clin Nutr 85, 54 –59.
Pfeifer M, Begerow B, Minne HW, et al. (2001) Effects of a
short-term vitamin D(3) and calcium supplementation on
blood pressure and parathyroid hormone levels in elderly
women. J Clin Endocrinol Metab 86, 1633 –1637.
Schluter KD & Piper H (1998) Cardiovascular actions of parathyroid hormone and parathyroid hormone-related peptide.
Cardiovasc Res 37, 34 –41.
Amann K, Tornig J, Flechtenmacher C, et al. (1995) Bloodpressure-independent wall thickening of intramyocardial
arterioles in experimental uraemia: evidence for a permissive
action of PTH. Nephrol Dial Transplant 10, 2043 –2048.
Somjen D, Weisman Y, Kohen F, et al. (2005) 25-Hydroxyvitamin D3-1a-hydroxylase is expressed in human vascular
smooth muscle cells and is upregulated by parathyroid
hormone and estrogenic compounds. Circulation 111,
1666– 1671.
Schluter KD & Piper HM (1992) Trophic effects of catecholamines and parathyroid hormone on adult ventricular cardiomyocytes. Am J Physiol 263, H1739–H1746.
Perkovic V, Hewitson TD, Kelynack KJ, et al. (2003) Parathyroid hormone has a prosclerotic effect on vascular
smooth muscle cells. Kidney Blood Press Res 26, 27– 33.
Andersson P, Rydberg E & Willenheimer R (2004) Primary
hyperparathyroidism and heart disease – a review. Eur
Heart J 25, 1776– 1787.
Garcia de la Torre N, Wass JA & Turner HE (2003) Parathyroid adenomas and cardiovascular risk. Endocr Relat Cancer
10, 309 – 322.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
1873
Martin-Ventura JL, Ortego M, Esbrit P, et al. (2003) Possible
role of parathyroid hormone-related protein as a proinflammatory cytokine in atherosclerosis. Stroke 34, 1783– 1789.
Foley RN, Parfrey PS & Sarnaak MJ (1998) Clinical epidemiology of cardiovascular disease in chronic renal disease. Am J
Kidney Dis 32, 5 Suppl. 3, S112 – S119.
Khajehdehi P & Taheri S (2003) Effect of oral calcitriol pulse
therapy on the lipid, calcium, and glucose homeostasis of
hemodialysis patients: its safety in a combination with oral
calcium carbonate. J Ren Nutr 13, 78– 83.
Lacour B, Basile C, Drueke T, et al. (1982) Parathyroid function and lipid metabolism in the rat. Miner Electrolyte Metab
7, 157 – 165.
Chiu KC, Chu A, Go VLW, et al. (2004) Hypovitaminosis D
is associated with insulin resistance and b cell dysfunction.
Am J Clin Nutr 79, 820 –825.
John WG, Noonan K, Mannan N, et al. (2005) Hypovitaminosis D is associated with reductions in serum apolipoprotein
A-I but not with fasting lipids in British Bangladeshis. Am J
Clin Nutr 82, 517 – 522.
Barger-Lux MJ, Heaney RP, Lanspa SJ, et al. (1995) An
investigation of sources of variation in calcium absorption
efficiency. J Clin Endocrinol Metab 80, 406 – 411.
Denke MA, Fox MM & Schulte MC (1993) Short-term dietary
calcium fortification increases fecal saturated fat content and
reduces serum lipids in men. J Nutr 123, 1047 – 1053.
Reid IR (2004) Effects of calcium supplementation on
circulating lipids: potential pharmacoeconomic implications.
Drugs Aging 21, 7– 17.
Vaskonen T, Mervaala E, Sumuvuori V, et al. (2002) Effects of
calcium and plant sterols on serum lipids in obese Zucker
rats on a low-fat diet. Br J Nutr 87, 239 – 245.
Van der Meer R, Welberg JW, Kuipers F, et al. (1990) Effects
of supplemental dietary calcium on the intestinal association
of calcium, phosphate, and bile acids. Gastroenterology 99,
1653 –1659.
Malik S (2003) Transcriptional regulation of the apolipoprotein AI gene. Front Biosci 8, d360 –d368.
Auwerx J, Bouillon R & Kesteloot H (1992) Relation between
25-hydroxyvitamin D3, apolipoprotein A-1 and high density
lipoprotein cholesterol. Aterioscler Thromb 12, 671 –674.
Wehmeier K, Beers A, Haas MJ, et al. (2005) Inhibition
of apolipoprotein AI gene expression by 1,25-dihydroxyvitamin D3. Biochim Biophys Acta 1737, 16 –26.
Downloaded from https://www.cambridge.org/core. IP address: 18.215.181.253, on 26 Nov 2021 at 03:04:08, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0007114512000098
Vitamin D3 supplementation and risk of CVD