Examine-Issue 73 PDF

Issue #73 November 2020
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Table of Contents
NERD News: The gut microbiome probably plays a significant role in type 1 diabetes
Recent research provides substantial evidence that gut microbiota can play a big part in new-
onset type 1 diabetes.
Can switching from meat to plant-based meat alternatives reduce cardiovascular disease
risk?
This study found that replacing meat with Beyond Meat lowers both TMAO and LDL-C.
Deep Dive: Does beta-alanine improve training performance?

If there are any effects present, they're mostly small. But small effects can still be worthwhile
for some competitive athletes.
Probiotics for celiac disease

The current evidence is promising but should be seen as preliminary and weak. A lot more
research needs to be done to see which probiotics, if any, work well for celiac disease.
Nerd Nulls: September-October 2020

Know new nulls now!
Is honey an effective remedy for symptoms of upper respiratory tract infections?

This meta-analysis hints at a small-to-moderate effect, but the overall quality of the evidence
ain't great.
Deep Dive: Does supplementing the sunshine vitamin impact colorectal cancer outcomes?
This meta-analysis suggests that supplementing vitamin D can improve cancer-specific
outcomes in people with colorectal cancer.
Deep Dive: Reducing common vertigo with vitamin D and calcium

This large, long trial found a pretty strong effect of supplementation on benign paroxysmal
positional vertigo recurrence. But there are some problems beneath the surface of these
promising findings.
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From the Editor
As the days grow shorter and colder in the Northern Hemisphere, we’ve decided to cover a handful of
seasonally relevant studies in this issue of NERD. One examines how useful honey is for symptoms of
upper respiratory tract infection. (Short answer: maaaayybe, kind of?) Two others that I want to focus on
here involve the sunshine vitamin: vitamin D.
Vitamin D’s effects are wide-ranging, given the ubiquity of the vitamin D receptor throughout the body.
But just because vitamin D is essential doesn’t necessarily mean that supplementing it is useful for
everyone. Indeed, many trials looking at the effects of vitamin D supplementation haven’t yielded very
promising results. There are a few exceptions, though. One signal that’s been popping out through the
noise has been vitamin D’s effect on cancer mortality.
While the current evidence doesn’t strongly support the idea that vitamin D supplementation can
prevent getting cancer in the general population, there’s been growing evidence that supplementation
can reduce the risk of dying from cancer. We covered this topic in NERD last year by looking at a meta-
analysis examining cancer risk and mortality in general. In this issue of NERD, we narrow the focus a bit
and review a meta-analysis specifically about vitamin D supplementation’s effect on colorectal cancer.
The results are promising: supplementation seems to lower the risk of dying from colorectal cancer in
those who already have cancer, with the data hinting at (but not strongly suggesting) a dose-response
effect.
Couple this analysis with a hot-off-the-presses secondary analysis of the VITAL trial suggesting that
vitamin D supplementation can reduce the risk of advanced cancer, and we’re starting to see the outlines
of a possible mechanism emerging: vitamin D supplementation could reduce the risk of dying from
cancer by reducing the risk of advanced, more deadly cancer. This hypothesis is far from certain, but
given how big of a deal cancer is, I find these findings to be among some of the more exciting ones in the
world of supplement research. I’ll be keeping an eye on how things go.
We also cover another vitamin D study in this issue that looks quite promising on its face: the effect of
vitamin D supplementation on one of the most common types of vertigo. But while the effect was
significant and the study was both large and had a pretty long duration, there are enough problems with
the study that makes me doubt how reliable the reported results are. Read on to see if you agree with my
take!
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Gregory Lopez, MA, PharmD
Editor-in-chief, Nutrition Examination Research Digest
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NERD News: The gut microbiome probably plays a
significant role in type 1 diabetes
 Tags: Gut Health, Microbiome, Diabetes
 Study under review: Faecal microbiota transplantation halts progression of human new-onset
type 1 diabetes in a randomised controlled trial
 Read this article online at Examine.com
Type 1 diabetes (T1D) is an autoimmune disease characterized by insufficient insulin production as a

result of T-cell-mediated destruction of beta cells in the pancreas. It commonly occurs in children but can
also develop in adults. While disease management is made possible through lifelong insulin injections,
there is no cure for T1D, and its cause is not fully understood.
Recently, an increasing number of studies began investigating whether or not the gut microbiota plays a
role in T1D pathophysiology. In cross-sectional and case-controlled studies, significant differences were
found when researchers compared the microbial composition of participants with T1D to healthy
controls, such as a decreased Firmicutes:Bacteroides ratio[1] and less abundant Lactobacillusand
Bifidobacterium[2] populations. These alterations are associated with impaired short-chain fatty acid
production and a weak intestinal epithelial barrier, pointing to a potential mechanism for T1D. Without a
strong barrier, bacteria from the gut can “leak” into the body’s circulatory system and provoke an
immune response. If these bacteria also mimic the body’s own beta cells, they may prime the immune
system to recognize beta cells as an enemy, initiating the development of T1D.
Thus, altering the gut microbiota in people with T1D may be a potential treatment strategy. In diabetic
mouse studies, administration of the short-chain fatty acids butyrate and acetate were able to improve
beta cell function[3], but T1D human studies using butyrate showed little effect[4] on disease progression
or management. This led researchers to a new idea: using fecal microbiota transplantation (FMT) as a
treatment for T1D.
In this 12-month randomized controlled trial[5], 20 new-onset (less than six weeks) participants with T1D
(aged 18–35) were assigned to one of two FMT groups: autologous (self as donor) or allogenic (healthy
donor matched for age and sex). Three fecal transplantations were administered by a nasoduodenal tube
(a tube inserted through the nose and passed down to the small intestine) using fresh feces at zero, two,
and four months into the study. The primary outcome was preservation of stimulated C-peptide release
after a mixed meal test at 12 months, a test widely used[6] to measure pancreatic beta cell function.
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Secondary outcomes were changes in glycemic control, fasting plasma metabolites, T-cell autoimmunity,
small intestinal gene expression profile, and intestinal microbiota composition.
At 12 months, mean fasting C-peptide responses were preserved in the autologous FMT group but
declined in the allogenic FMT group compared to baseline levels. The autologous FMT group also had
significantly more functioning residual beta cells than the allogeneic group at 12 months. This was an
unexpected finding, as the authors hypothesized the allogeneic FMT would be more beneficial. This may
be related to the increased inflammation present in people with T1D at the time of diagnosis, which
would subsequently decrease the host’s tolerance for a less immunologically compatible FMT (someone
other than the self as a donor). Regardless, both groups still had better C-peptide responses than
expected in a person with T1D without a year of treatment, used similar amounts of exogenous insulin,
and had comparable glycemic control. Hence, FMT may prolong residual beta cell function in people with
T1D with no serious adverse events.
Determining the potential mechanisms behind these benefits was the goal of the secondary outcomes.
Interestingly, positive FMT outcomes were not related to changes in bacterial strains producing short-
chain fatty acids, but rather to changes in bacterial strains producing certain fasting plasma metabolites,
specifically 1-myristoyl-2-arachidonoyl-GPC (MA-GPC) and 1-arachidonoyl-GPC (A-GPC). When comparing
the small intestinal gut microbiota composition between groups, the autologous FMT group had a lower
relative abundance of Prevotella 1, Prevotella 2, and Streptococcus oralis compared to the allogeneic
group at six months. An increase in any of these species correlated negatively to glucose regulation,
metabolic function, and the metabolites MC-GPC and A-GPC. When comparing changes in fecal
microbiota composition, the autologous FMT group had significantly higher levels of Desulfovibrio piger
at 6 and 12 months, which correlated positively with improvements in fasting C-peptide responses and A-
GPC levels.
Moreover, D. piger was associated with a reduction in CD4+ CXCR3+ and CD8+ CXCR3+ T-cells, which
mediate the immune system’s attack on beta cells in T1D. It is possible that D. piger dampens
autoimmunity by producing not only A-GPC, but also hydrogen sulfide, a molecule known to regulate the
immune system. In fact, supplementation with taurine[7] or N-acetyl cysteine[8], both of which may
increase hydrogen sulfide production, can preserve pancreas mass in T1D rodents when administered
during the early years of life.
Although these are exciting findings, there are some important considerations to keep in mind. One is
related to the importance of baseline testing in identifying what kind of people with T1D are most likely
to respond positively to FMT. For example, the expression of CCL22 and CCL5 genes in duodenal biopsies
at baseline were highly predictive of preserved beta cell function at 12 months, no matter the FMT donor
group, as were baseline measures of fecal microbial composition and metabolic pathways. Hence,
additional research with larger sample sizes is needed to help elucidate the specific population of people
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with T1D for whom FMT is a viable treatment option. Second, no biopsies were taken of the pancreas (not
possible in living participants), and this is the area where the most important immunological effects
likely occur. Third, as mentioned previously, T1D commonly occurs in adolescents, and the participants
in this study were all over the age of 18. Whether or not these findings are relevant to earlier onset T1D is
unknown. Fourth, there was no true placebo control group.
Finally, and potentially most importantly, this is a medical procedure and not something that can be
achieved or attempted outside of the care of an experienced, certified medical provider. The results of
this study cannot be extrapolated to support the use of certain supplements or probiotics to support beta
cell function in people with T1D.
So why are we bothering covering it? Partially to get out the message that these results don’t necessarily
translate directly to supplementation. But also because this is quite strong evidence that gut microbiota,
especially in the small intestine, really does play a role in type in serious autoimmune diseases like T1D.
Determining the magnitude of that role and how it can best be harnessed for the purposes of treatment
requires additional research, but results like these strongly justify further research into the issue.
^ Go back to table of contents
 References
1. ^ Stefano Bibbò, et al. Is there a role for gut microbiota in type 1 diabetes pathogenesis?.
Ann Med. (2017)
2. ^ He Zhou, et al. Evaluating the Causal Role of Gut Microbiota in Type 1 Diabetes and Its
Possible Pathogenic Mechanisms. Front Endocrinol (Lausanne). (2020)
3. ^ Eliana Mariño, et al. Gut microbial metabolites limit the frequency of autoimmune T
cells and protect against type 1 diabetes. Nat Immunol. (2017)
4. ^ Pieter F de Groot, et al. Oral butyrate does not affect innate immunity and islet
autoimmunity in individuals with longstanding type 1 diabetes: a randomised controlled
trial. Diabetologia. (2020)
5. ^ Pieter de Groot, et al. Faecal microbiota transplantation halts progression of human
new-onset type 1 diabetes in a randomised controlled trial. Gut. (2020)
6. ^ Emma Leighton, Christopher Ar Sainsbury, Gregory C Jones. A Practical Review of C-
Peptide Testing in Diabetes. Diabetes Ther. (2017)
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7. ^ E Arany, et al. Taurine supplement in early life altered islet morphology, decreased
insulitis and delayed the onset of diabetes in non-obese diabetic mice. Diabetologia.
(2004)
8. ^ Lital Argaev Frenkel, et al. N-Acetyl-l-Cysteine Supplement in Early Life or Adulthood
Reduces Progression of Diabetes in Nonobese Diabetic Mice. Curr Dev Nutr. (2018)
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Can switching from meat to plant-based meat
alternatives reduce cardiovascular disease risk?
 Tags: Cardiovascular Disease, Plant Protein, Animal Protein, Red Meat, Diet, Cholesterol, LDL, CVD
 Study under review: A randomized crossover trial on the effect of plant-based compared with
animal-based meat on trimethylamine-N-oxide and cardiovascular disease risk factors in generally
healthy adults: Study With Appetizing Plantfood-Meat Eating Alternative Trial (SWAP-MEAT)
Quick Takes
What was the question? How does consuming plant-based meat products affect
cardiovascular risk markers, compared to regular meat?
How was it answered? Researchers conducted a randomized controlled crossover

trial.
Who was studied? The participant population included healthy people who ate at
least one daily serving of meat at baseline.
What was the intervention? Participants ate at least two daily servings of meat (a
mix of sausage, red meat, and chicken breast) or of a processed plant-based meat
substitute (Beyond Meat).
What's the main takeaway? Trimethylamine-N-oxide (TMAO) levels were about

40% lower in the plant-based meat group compared to the animal product group.
Bodyweight was also slightly lower, while LDL-C was about 11 mg/dL lower,
compared to the meat-eating group.
Any caveats? The effect of the intervention on TMAO may have depended on the
order the participants ate the plant-based food product and meat. This may be
due, in part, to the fact that there was no washout period between diets, which
could have led to some carryover effects from the first intervention to the second.
However, because this was an exploratory study, this order-dependent effect may
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also have also occured due to chance. Also, whether TMAO is causally related to
heart disease is not a completely settled matter.
What was the question?

What are the effects of replacing animal meat with a processed plant-based meat substitute (Beyond
Meat) on health and cardiovascular risk factors?
Why was the question worth asking?

Plant-based diets and products are rapidly growing in popularity[1], as they are believed to have potential
health[2] and environmental benefits[3]. Hence, a diet primarily based on plant foods is generally
recommended[4] by leading institutions. However, transitioning from mostly meat to a more plant-based
diet is challenging for most people[5] due to taste preferences, culinary traditions, and cultural norms.
Plant-based meat substitutes (‘plant-meat’) now offer an attractive alternative to animal meat. Designed
to resemble the taste, texture, and appearance of traditional meat products, the popularity of plant-meat
has increased rapidly in recent years[6], both for vegans and vegetarians, but also for meat-eating
consumers. Still, the question remains: is plant-meat a healthy alternative to animal meat?
The rise of plant-meat products has raised a lot of criticism[7]. Plant-based meat products are considered
ultra-processed foods, according to the NOVA food classification system[8], as described in Figure 1. This
can be a problem because research has shown that diets high in ultra-processed foods results in higher
energy intake and weight gain[9]. Furthermore, plant-meats are often relatively high in sodium and
saturated fats, which are, in high amounts, associated with an increased risk of cardiovascular disease
(CVD)[10]. In other words: Just because something is made out of plants does not per se make it a healthy
product.
Figure 1: What “ultra-processed” means according to the NOVA food classification system
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Reference: Monteiro et al. Public Health Nutr. 2018 Jan.[8]
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Still, plant-based alternatives are often regarded as healthier than animal meat, especially red meat[11].
These foods have higher fiber and lower cholesterol and saturated fats content. There are also a number
of emerging risk factors that are positively linked to regular consumption of red meat, but are decreased
in vegans and vegetarians. Most importantly among these are trimethylamine-N-oxide (TMAO)[12] and
insulin-like growth factor 1 (IGF-1)[13]. In particular, TMAO could be mechanistically linked to the
pathogenesis of atherosclerotic heart disease[14], There are still some questions[15] about whether
TMAO’s link to heart disease is causal, though. If elevated TMAO levels do raise the risk of heart disease,
then red meat could contribute to heart disease risk because TMAO is primarily derived from the nutrient
precursors choline and carnitine, which both naturally occur in high amounts in red meat.
Since meat consumption is linked to increased TMAO levels, the authors of the present study
hypothesized that replacement of animal meat with plant-based alternatives might reduce TMAO levels.
If this were the case, a dietary shift from animal to plant meat might also alleviate the risk of incident CVD
development and adverse CVD events, such as heart attack, stroke, and death. Hence, decreasing
systemic levels of TMAO by reducing red meat consumption may be a potential therapeutic strategy for
reducing the risks of CVD development and progression.
Plant-based meat alternatives are becoming increasingly popular due to their potential health
and environmental benefits. Frequent consumption of red meat increases systemic levels of
TMAO, which correlates with an increased CVD risk. Replacement of red meat with plant-meat
may be a good strategy to reduce TMAO levels and the associated CVD risks.
How was the question answered?

The researchers performed a randomized controlled crossover trial in which 38 healthy participants ages
21–75 were instructed to consume at least two servings of either plant-based meat substitutes (‘Plant’) or
animal meat (‘Animal’) for eight weeks, respectively. The study design did not incorporate a washout
phase. The first group ate the plant diet, followed by the animal diet, while the second group did the
reverse. Prior to the study, participants completed a brief questionnaire about current habitual meat
intake and were instructed to track their food intake for three days every second week.
All plant products were supplied by Beyond Meat, who financed the study under review. Animal products
included a mix of sausage, red meat, and chicken breast. Nutrient profiles for plant-meat and animal
meat products were very similar, with two exceptions: plant products had higher fiber and lower
saturated fat content. Overall, daily energy, sodium, and protein intake were not significantly different
between both groups, although saturated fat intake was lower in the Plant group. Some key nutrition
facts and sample foods for the two groups are shown in Figure 2.
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Figure 2: Some key nutrition facts for the two groups
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The inclusion and exclusion criteria were designed to recruit only healthy participants with a bodyweight
of more than 110 pounds, blood pressure of less than 160 mmHg systolic and less than 90 mmHg
diastolic, and suffering from no major diseases, including cardiovascular, gastrointestinal, hepatic, and
others. Participants were mostly women (67%), Caucasian (69%), and college-educated (83%). BMI
ranged from 18–39 (average: 27.4), and age ranged from 21–75 years. Notably, all participants were meat-
eaters prior to the stud, consuming, on average, one daily serving of meat.
The study was preregistered. The original primary outcomes were declared as changes in fasting serum
levels of TMAO and IGF-1 compared to baseline, although no power calculation was performed. Sample
size was determined by the researchers’ available resources. Notably, IGF-1 was demoted to a secondary
outcome after the study was performed. This is relevant when determining how much confidence can be
placed in the results. Other secondary outcomes included fasting lipids, insulin, blood pressure, and
bodyweight. Baseline parameters were determined at the beginning of the study, but there was no
reassessment after the crossover. Blood samples were collected at baseline and weeks 2, 4, 8 (phase I),
10, 12, and 16 (phase 2). The researchers performed microbiome analyses of all participants, as TMAO
originates from gut bacteria. The statistical analysis was performed by an independent institute.
The researchers conducted a randomized, crossover trial to compare the effects of consuming at
least two servings of plant-meat, compared to animal meat, on health and CVD risk factors. The
primary outcome was fasting serum TMAO. Secondary outcomes included fasting IGF-1, lipids,
glucose, insulin, blood pressure, and bodyweight.
What was the answer?

On average, TMAO levels were significantly lower for plant-based meat alternatives (2.7 µM) than for
animal meat (4.7 µM), which corresponds to a relative decrease of -43%. However, a significant order
effect was observed: TMAO concentrations were only lower for the Animal-Plant group (-63%), but not for
the Plant-Animal group (-24%, not statistically significant). Analysis of participant microbiomes did not
reveal any differences that could explain this order effect in terms of responder and nonresponder
effects.
Also, the researchers found no differences in fasting IGF-1, insulin, glucose, and blood pressure. However,
LDL cholesterol (-9%, or -11 mg/dL) and bodyweight (-1%) were reduced during the plant phase,
independent of the intervention sequence. This was noted as unexpected by the researchers because
saturated fat and energy intake were similar for both groups. While the practical effects of the
bodyweight reduction were small, the changes in LDL cholesterol are somewhat clinically relevant, as
even small reductions in LDL levels are known to reduce cardiovascular mortality significantly[16].
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Assuming linearity, the reductions in LDL-C seen here would reduce the risk of cardiovascular disease by
roughly 6% in the longer term.
Consumption of plant-meat significantly lowered TMAO levels, but only in the Plant-Meat group,
not in the Meat-Plant group. IGF-1 levels remained unchanged. However, LDL cholesterol and
bodyweight were reduced during the plant-meat phase.
How much should you trust the answer?

If you follow nutrition research, you may already be familiar with the claim that eating red meat increases
TMAO levels, which, in turn, raises CVD risk. This relationship implies eating less red meat is beneficial for
overall health. At first look, the present study seems to further validate these claims. Before jumping to
that conclusion, consider the context of the findings: How reliable is TMAO as a novel CVD risk factor? And,
do these changes in TMAO levels have clinical relevance? If so, how much risk reduction can be expected? To
answer these questions, take a closer look at the current body of literature. Specifically, there are five
aspects to consider:
How reliable is TMAO as a risk factor for CVD?
First, a general word: determining the true nature of dietary-health relationships is very difficult, and
TMAO is no exception. TMAO is a relatively new risk factor for CVD that emerged about 10 years ago[17].
Since then, the mechanistic role of TMAO was studied in animal model systems[17], and its potential
application as a clinical risk factor for CVD was supported by three[18] recent[19] meta-analyses[20].
However, all of these meta-analyses also recognized that this research is still in an early (preliminary)
phase, and that more research is required to verify the applicability of TMAO as a valid biomarker with
clinical validity and utility[21]. In stark contrast to the early evidence, a recent study using Mendelian
randomization analysis[15] (a powerful method to assess causality, covered in NERD #58) found no causal
relationship between TMAO and CVD. Instead, the researchers suggested that the observational evidence
may be the result of confounding or reverse causality (i.e., CVD increases TMAO levels, not the other way
around).
Another caveat of the present study is the influence of fish consumption. As fish and seafood also contain
high amounts of TMAO precursors[22], they should also be associated with CVD. However, fish is not
linked to CVD. On the contrary: fish is generally recognized as cardioprotective. This puzzling paradox
further questions the validity of TMAO as a CVD risk factor.
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Taken together, the current body of evidence suggests that TMAO is on its way to being treated as a risk
marker for CVD, even though its role in CVD is not fully understood yet. For that reason, the practical
implications of the present study should be interpreted with great caution.
Are the changes clinically relevant? How much risk reduction can be expected?
Assuming clinical validity and utility of TMAO as a risk factor for CVD, the changes in TMAO levels
observed in the present study may have clinical relevance. According to recent[20] meta[19]-analyses[23],
an increase in relative risk for all-cause mortality of 7.6% per 10 µM increment of TMAO was found after,
on average, 4.3 years. In the present study, participants in the Animal-Plant group experienced, on
average, an absolute change in TMAO levels of 3.5 µM. Assuming these changes, followed over weeks, can
be extended to several years, and assuming a linear relationship (both big assumptions!), a diet high in
red meat (at least two servings per day) would correspond to a 2.7% increase in relative risk of mortality,
compared to eating plant-meat. If TMAO is causally linked to CVD (another big assumption!), this
reduction in relative risk would have clinical relevance. Despite this potential relevance, it’s very
important to keep in mind the included limitations and assumptions. Taken together, the potential
benefits are speculative, at best.
The same speculative approach can be taken to evaluating the clinical significance of the LDL cholesterol
changes observed in this study. Again, presuming a linear relationship and that these changes hold in the
longer term (again, both big assumptions!), previous research[16] suggests that the reductions in LDL-C
seen in this study would reduce the risk of cardiovascular disease by roughly 6% over the long haul.
While this specific number is open to question, it’s much more clear[24] that LDL cholesterol plays a
causal role in cardiovascular disease, compared to TMAO’s more tenuous footing.
Are the findings of this study consistent?
A previous randomized-controlled trial[12] investigating red meat, white meat, and non-meat protein has
shown that a diet enriched in red meat (at least two servings per day) substantially increases TMAO levels
by approximately three-fold after four weeks. The present study shows a nearly two-fold increase in
TMAO levels after eight weeks, which is slightly lower, but the general trend is still in good agreement.
This indicates that an intervention time frame of just a few weeks is sufficient to reduce TMAO levels
significantly. Thus, the duration of intervention used here (eight weeks) seems appropriate for the study.
What about the order effect?
The present study found a significant order effect: TMAO levels were decreased in the Animal-Plant
sequence, but not the Plant-Animal sequence. The authors first suggested that this is due to microbiome
changes induced by the first eight weeks of consuming only plant-based substitutes. However, the
microbiome analysis revealed no significant differences among the groups. There are three possible
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explanations for this: First, the analytical method was insufficient to detect the microbiome-associated
alterations. Second, meat consumption may increase gut permeability (leaky gut), thus increasing
systematic TMAO levels. Third, the renal excretion of TMAO was increased during the Plant phase prior to
the Animal phase. A previous trial[12] found that renal excretion of TMAO was significantly reduced after
four weeks of red meat ingestion. However, the mechanism contributing to the altered fractional renal
excretion remains unknown. One might speculate that the eight-week Plant phase may have improved
renal excretion capacity, thus clearing TMAO more efficiently during the Animal phase. In any case, the
order effect was an unexpected result and must be further researched. A final, less exciting option is that,
given the exploratory nature of this research, the difference could just be due to random chance.
Are there any other limitations?
Besides the unexpected and still unexplained order effect, the present study had several other
limitations. First, no second baseline measurement and washout period were performed after the
crossover. Furthermore, researchers observed a high degree of variability among participants. In
particular, three participants in the Animal-Plant group had disproportionately large alterations in TMAO
levels, while others had little changes from baseline. This indicates a potential personalized response in
TMAO levels to red meat consumption, possibly due to genetic predispositions or microbiome-associated
variations. However, the researchers were unable to identify meaningful differences between responders
and nonresponders.
Second, contrary to the expectations of the researchers, no changes in IGF-1 were observed. Notably,
IGF-1 was moved from a primary outcome (preregistration) to a secondary outcome after the study was
completed. The researchers initially hypothesized that IGF-1 levels would change during the
intervention, as previous studies show that IGF-1 levels are increased in vegetarians[13] and vegans[25],
compared to omnivores. It is thus somewhat suspicious that the non-significant primary outcome IGF-1
was moved to a secondary outcome. This is also particularly relevant in light of Beyond Meat’s
sponsorship of this study. In short, these limitations are good reasons to be critical of the results and
careful with the interpretation.
Third, the dietary intervention consisted only of two daily servings of plant-meat and animal meat
products, while the remainder of the diet was self-selected and potential interactions were not assessed.
Taken together, the present study has some internal limitations and contradictions that question the
applicability of its findings for making general dietary recommendations.
Consuming plant-meat instead of red animal meat is an effective strategy for reducing TMAO and
LDL cholesterol levels significantly in just a few weeks. Assuming the clinical validity and utility of
TMAO will be further verified in the future, this simple dietary intervention may reduce the
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relative risk of CVD and all-cause mortality by a few percent. However, the present study has
some severe limitations, and the applicability of TMAO as a valid biomarker for CVD still needs to
be elucidated. In contrast to TMAO, changes in LDL cholesterol may be even more important, as
this risk factor is very well established by now.
What’s the take-home?

The study under review shows that plant-meat, as opposed to red animal meat, can significantly reduce
TMAO levels and, to a smaller extent, LDL-cholesterol and bodyweight, but not IGF-1 levels. Given the
growing body of evidence suggesting a mechanistic link between TMAO and LDL-cholesterol as risk
factors for CVD, plant-meat may provide a feasible meat alternative to effectively reduce both, and thus
also decrease the risk of CVD to some extent. However, since the direct contribution of TMAO to CVD is
still not fully understood, and the effects of dietary interventions on TMAO have only been investigated to
a modest extent, there is still more research needed. For now, it’s reasonable to conclude that plant-
based meat patties and sausages are, in any case, safe to consume and may also have a potential
cardioprotective edge over red animal meat.
Have you tried plant-meat? Does this study motivate you to replace meat with plant-based meat
substitutes? Let us know your thoughts in the NERD Facebook group.
 References
1. ^ Hyun Jung Lee, et al. Status of meat alternatives and their potential role in the future
meat market - A review. Asian-Australas J Anim Sci. (2020)
2. ^ Dinu M, et al. Vegetarian, vegan diets and multiple health outcomes: A systematic
review with meta-analysis of observational studies. Crit Rev Food Sci Nutr. (2017)
3. ^ Alice Rosi, et al. Environmental impact of omnivorous, ovo-lacto-vegetarian, and vegan
diet. Sci Rep. (2017)
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4. ^ Walter Willett, et al. Food in the Anthropocene: the EAT-Lancet Commission on healthy
diets from sustainable food systems. Lancet. (2019)
5. ^ Ruben Sanchez-Sabate, Joan Sabaté. Consumer Attitudes Towards Environmental
Concerns of Meat Consumption: A Systematic Review. Int J Environ Res Public Health.
(2019)
6. ^ Deepak Choudhury, et al. Commercialization of Plant-Based Meat Alternatives. Trends
Plant Sci. (2020)
7. ^ Alexandra E Sexton, Tara Garnett, Jamie Lorimer. Framing the future of food: The
contested promises of alternative proteins. Environ Plan E Nat Space. (2019)
8. ^ a b Monteiro CA, et al. The UN Decade of Nutrition, the NOVA food classification and the
trouble with ultra-processing. Public Health Nutr. (2018)
9. ^ Kevin D Hall, et al. Ultra-Processed Diets Cause Excess Calorie Intake and Weight Gain:
An Inpatient Randomized Controlled Trial of Ad Libitum Food Intake. Cell Metab. (2020)
10. ^ David M Johns. Dietary Sodium and Cardiovascular Disease Risk. N Engl J Med. (2016)
11. ^ Marta Lonnie, et al. Exploring Health-Promoting Attributes of Plant Proteins as a
Functional Ingredient for the Food Sector: A Systematic Review of Human Interventional
Studies. Nutrients. (2020)
12. ^ a b c Zeneng Wang, et al. Impact of chronic dietary red meat, white meat, or non-meat
protein on trimethylamine N-oxide metabolism and renal excretion in healthy men and
women. Eur Heart J. (2019)
13. ^ a b Naomi E Allen, et al. The associations of diet with serum insulin-like growth factor I
and its main binding proteins in 292 women meat-eaters, vegetarians, and vegans. Cancer
Epidemiol Biomarkers Prev. (2002)
14. ^ Koeth RA, et al. Intestinal microbiota metabolism of L-carnitine, a nutrient in red meat,
promotes atherosclerosis. Nat Med. (2013)
15. ^ a b Jia J, et al. Assessment of Causal Direction Between Gut Microbiota-Dependent
Metabolites and Cardiometabolic Health: A Bidirectional Mendelian Randomization
Analysis. Diabetes. (2019)
16. ^ a b Cholesterol Treatment Trialists’ (CTT) Collaboration, et al. Efficacy and safety of
more intensive lowering of LDL cholesterol: a meta-analysis of data from 170,000
participants in 26 randomised trials. Lancet. (2010)
17. ^ a b Wang Z, et al. Gut flora metabolism of phosphatidylcholine promotes cardiovascular
disease. Nature. (2011)
18. ^ Katie A Meyer, Jonathan W Shea. Dietary Choline and Betaine and Risk of CVD: A
Systematic Review and Meta-Analysis of Prospective Studies. Nutrients. (2017)
19. ^ a b Schiattarella GG, et al. Gut microbe-generated metabolite trimethylamine-N-oxide
as cardiovascular risk biomarker: a systematic review and dose-response meta-analysis.
Eur Heart J. (2017)
20
20. ^ a b Qi J, et al. Circulating trimethylamine N-oxide and the risk of cardiovascular
diseases: a systematic review and meta-analysis of 11 prospective cohort studies. J Cell
Mol Med. (2018)
21. ^ Virginia B Kraus. Biomarkers as drug development tools: discovery, validation,
qualification and use. Nat Rev Rheumatol. (2018)
22. ^ Landfald B, et al. Microbial trimethylamine-N-oxide as a disease marker: something
fishy?. Microb Ecol Health Dis. (2017)
23. ^ Heianza Y, et al. Gut Microbiota Metabolites and Risk of Major Adverse Cardiovascular
Disease Events and Death: A Systematic Review and Meta-Analysis of Prospective Studies.
J Am Heart Assoc. (2017)
24. ^ Ference BA, et al. Low-density lipoproteins cause atherosclerotic cardiovascular
disease. 1. Evidence from genetic, epidemiologic, and clinical studies. A consensus
statement from the European Atherosclerosis Society Consensus Panel. Eur Heart J.
(2017)
25. ^ N E Allen, et al. Hormones and diet: low insulin-like growth factor-I but normal
bioavailable androgens in vegan men. Br J Cancer. (2000)
21
Deep Dive: Does beta-alanine improve training
performance?
 Tags: Exercise Performance, Supplementation, Beta-Alanine
 Study under review: Effects of Beta-Alanine Supplementation on Physical Performance in Aerobic-

Anaerobic Transition Zones: A Systematic Review and Meta-Analysis
Quick Takes
What was the question? How does beta-alanine supplementation affect
performance around the aerobic-anaerobic transition zone (60–100% of VO2max)?
How was it answered? Researchers conducted a meta-analysis of randomized

controlled trials.
Who was studied? Participants included healthy adults undergoing a variety of

physical performance tests in the aerobic-anaerobic transition zone.
What was the intervention? The interventions included both acute (dosing no
more than 24 hours before the performance test) and chronic (daily dosing for up
to 10 weeks) beta-alanine supplementation. Doses ranged from 1.5 to 7 grams.
What’s the main takeaway? Researchers observed small effects on most

performance metrics. Beta-alanine supplementation had a large effect on limited
distance test performance. However, both of these effects were not statistically
significant.
Any caveats? Given that the effects seen here were not statistically significant,
more evidence would be useful to determine beta-alanine’s efficacy. Also, the
authors did not perform any subgroup or sensitivity analyses, leaving open the
questions of whether some groups may benefit more from supplementation than
others, and whether any particular study had a strong influence on the meta-
analytic results.
22
Introduction
Nutritional supplements are a broad category that includes nutritional complements, such as protein
powder, and non-nutritional ergogenic aids, like caffeine. One of the most common goals for using them,
particularly in competitive sports, is to enhance performance. There are many supplements that, at least
in theory, can increase performance through different mechanisms. One such a mechanism involves the
delaying and reduction of muscle fatigue, which interferes with muscle function at higher exercise
intensities. In part, muscle fatigue results[1] from the accumulation of metabolites like hydrogen (H+)
ions, that reduce the muscle pH and affect muscular function.
Carnosine is a di-peptide formed by two amino acids: histidine and beta-alanine (BA). In muscle,
carnosine acts as an intracellular buffer, counteracting the increase in H+ during exercise. However,
dietary carnosine has a very low bioavailability in muscle tissue due to the presence[2] of carnosinase, a
carnosine degrading enzyme, in plasma. Due to this relationship, dietary BA supplementation has
become the method of choice for increasing muscle carnosine levels. This increase occurs[3] with
repeated consumption over time in order to accumulate carnosine in muscle, which lacks carnosinase.
Previous data[4] suggests a small benefit of BA supplementation on exercise capacity and performance.
However, the effect of BA specifically in the aerobic-anaerobic transition zone (60–100% VO2max) has not
been meta-analyzed. Examples of activities that exist in this zone include rowing, cycling, and running.
Dietary supplements that increase performance can be very valuable for athletes. One of the
main ways in which these supplements could work is by reducing muscle fatigue, which occurs, in
part, due to the accumulation of metabolites, such as hydrogen H+ ions. This leads to a decrease
in the cell’s pH and reduced function. One of the main pH buffers in muscle is carnosine, which is
composed of histidine and beta-alanine (BA). Supplementing BA has been shown to increase
carnosine levels in muscle and thus potentially counteract muscle fatigue during exercise.
However, whether it has any effect specifically during the aerobic-anaerobic transition zone has
not been determined.
What was studied?

This systematic review and meta-analysis included controlled studies that evaluated BA
supplementation (chronically or acutely) by healthy adults, and that tested physical performance in the
aerobic-anaerobic transition zone (60–100% VO2max) using time trial tests (TTT; how quickly a given
23
activity can be performed) or time to exhaustion (TTE; how long before exhaustion sets in for a given
activity) tests, the latter using either limited distance test (LDT) or limited time test (LTT). The study was
not preregistered.
Acute BA supplementation was considered when a single dose of BA was used between immediately
before and 24 hours before the physical test, while chronic supplementation included repeated doses of
BA for more than one day, up to 10 weeks.
The primary outcomes included TTT, LDT and LTT, while secondary outcomes included tests that were
performed in the studies being analyzed, such as capillary lactate concentration, absolute VO2max, heart
rate, and ratings of perceived exertion (RPE).
BA supplemented groups and controls were compared by calculating the standardized mean difference
(SMD) and its standard error. Additionally, net effect sizes were calculated and Cohen’s criteria were used
to interpret the magnitude of ES as trivial (less than 0.2), small (0.2–0.5), moderate (0.5–0.8), and large
(more than 0.8).
In total, 19 studies were included in the systematic review and meta-analysis. Eight studies used TTT,
nine used LTT, only one used LDT and one used both LTT and LDT. The authors did not report the amount
of participants included in the meta-analysis. The daily dose used ranged from 1.5 to 7 grams.
This meta-analysis included 19 studies that studied the effects of chronic or acute BA
supplementation on physical performance in the aerobic-anaerobic transition zone (60–100%
VO2max) were included in the meta-analysis. Primary outcomes were time trial or time to
exhaustion tests, while secondary outcomes included lactate concentration, absolute VO2max,
heart rate, and RPE.
What were the findings?

As shown in Figure 1, BA supplementation produced a small and non-significant reduction in TTT (-0.36,
95% CI -0.87–0.16; p=0.18), with moderate heterogeneity among studies (seven showed a positive effect
and three showed a negative effect). BA supplementation also showed a small, non-significant effect on
LTT (SMD, 0.25; 95% CI -0.01–0.51; p=0.06) and a large, non-significant effect on LDT (SMD, 4.27; 95% CI
-0.25–8.79; p=0.06), which came from only two studies (one study had two supplementation arms).
Heterogeneity in the LTT trials was low, but high on LDT.
Figure 1: Effects of beta-alanine supplementation with 95% confidence intervals
24
For all secondary outcomes, the effect was trivial and non-significant, with the exception of HR, where a
small, non-significant increase was observed.
BA supplementation only had a small, but not significant, positive effect in the total time and
limited time tests. No significant effects were observed for any other measures.
The bigger picture

Overall, BA didn’t appear to show any statistically significant effect on any of the measured parameters.
However, there is an important consideration to be noted regarding supplementation and performance:
a small effect might be the difference between winning and losing for elite and competitive athletes.
Furthermore, although the effect didn’t reach statistical significance, it was close, so there may, in fact,
be a small, real effect. While it can’t be relied on, there could be a pragmatically useful effect for
competitive athletes—if an effect exists at all.
In general, researchers studying nutrition supplements haven’t found any big effect on various
parameters, like increase in muscle mass with protein supplementation[5] or performance increase with
caffeine[6]. Therefore, it is possible that several supplements in combination are needed to show larger
effects. Some data[7] suggests that combining BA with sodium bicarbonate or creatine to buffer both
intracellular and blood H+ accumulation, respectively, might provide additive effects. There is also some
individual variability in the response to particular substances, such as caffeine[8], because genetic
25
differences alter the metabolism of these compounds in the body and thus, the response. In the case of
caffeine, the effects are big[9]. This is why it seems imperative that trial and error is necessary to
determine if BA provides beneficial effects. There are also individual characteristics that might influence
BA’s ergogenic effects. For example, meat and animal products contain[10] carnosine and serve as a food
source of BA. Accordingly, vegetarians have lower muscle levels of carnosine. Sex also appears to
modulate the content of carnosine in muscle, as women have been shown[11] to have lower levels than
males. Therefore, the effectiveness of BA supplementation might depend on the baseline status of
muscle carnosine, as well as the athlete’s sex.
The main limitations of this meta-analysis is that it included very few studies, and the doses used in
these studies were heterogeneous. The authors didn’t perform any subgroup or sensitivity analysis,
which is particularly important for the two main results (time trial and limited time tests), in which there
was one outlier study for each, which drives the SMD. The authors also don’t report the total number of
participants nor their characteristics (sex, weight, age, etc.), making it more difficult to interpret the
findings. The methodological weaknesses and mostly nonsignificant findings make it difficult to draw
strong conclusions from this study.
Although all the effects observed in the meta-analysis were small and statistically non-significant,
they might still be useful for competitive athletes if they exist. The potential benefit of BA
supplementation might also be dependent on its combination with other supplements, baseline
diet (vegetarian versus omnivore) or sex (male or female). Nevertheless, given the study’s
limitations, the findings must be interpreted with caution.
Frequently asked questions

Q. Why is beta-alanine, and not histidine, used to increase carnosine levels?
Beta-alanine is the rate-limiting substrate for carnosine synthesis. This is because[3] there are very low
levels of beta-alanine available in muscle tissue, and the concentration required for the synthesis of
carnosine is higher than that of histidine, which is abundant.
Q. Is there any health benefit from BA supplementation?
There is preliminary animal and in vitro data showing the potential benefits of beta-alanine on health,
including its ability to reduce[12] protein glycation and behave[13] as an antioxidant. Further studies are
required to determine if it has any meaningful effect in humans.
26
What should I know?
One of the key limitations of sports performance is muscle fatigue, which is caused, in part, by the
accumulation of metabolites produced during muscle metabolism, such as hydrogen ions, which
decrease the pH of the cell. Carnosine is a di-peptide formed by beta-alanine (BA) and histidine that
buffers this decrease in pH, counteracting muscle fatigue. There is previous evidence that suggests
supplementing with BA improves performance, but its specific effect on the aerobic-anaerobic transition
zone has not been evaluated in a meta-analysis.
The authors analyzed the effect of BA supplementation on performance using total time tests and time to
exhaustion tests (either limited distance or limited time tests). Overall, BA supplementation had a small,
non-significant positive effect on total time and limited time tests, and a large effect on limited distance
tests. However, the latter effect came from only two studies with high heterogeneity and should thus be
interpreted cautiously.
Overall, this and previous literature suggests that BA might have a small positive effect on performance,
which might be valuable to competitive athletes. However, the particular effect of BA supplementation
might depend on individual variables, such as diet (vegetarians have lower levels of carnosine), sex
(males have higher levels than females) and the presence of and interaction with other ingredients such
as sodium bicarbonate, caffeine, or creatine. Due to methodological limitations, as well as to the lack of
statistical significance in the differences, care must be taken when interpreting these findings.
How compelling are these borderline findings? Have your say over at the NERD Facebook forum!
 References
1. ^ Christopher W Sundberg, Robert H Fitts. Bioenergetic basis of skeletal muscle fatigue.

Curr Opin Physiol. (2019)
2. ^ Gardner ML, et al. Intestinal absorption of the intact peptide carnosine in man, and
comparison with intestinal permeability to lactulose. J Physiol. (1991)
27
3. ^ a b Sale C, Saunders B, Harris RC. Effect of beta-alanine supplementation on muscle
carnosine concentrations and exercise performance. Amino Acids. (2010)
4. ^ Saunders B, et al. β-alanine supplementation to improve exercise capacity and
performance: a systematic review and meta-analysis. Br J Sports Med. (2017)
5. ^ Morton RW, et al. A systematic review, meta-analysis and meta-regression of the effect
of protein supplementation on resistance training-induced gains in muscle mass and
strength in healthy adults. Br J Sports Med. (2018)
6. ^ Kyle Southward, Kay J Rutherfurd-Markwick, Ajmol Ali. The Effect of Acute Caffeine
Ingestion on Endurance Performance: A Systematic Review and Meta-Analysis. Sports
Med. (2018)
7. ^ Trexler ET, et al. International society of sports nutrition position stand: Beta-Alanine. J
Int Soc Sports Nutr. (2015)
8. ^ Pickering C, Kiely J. Are the Current Guidelines on Caffeine Use in Sport Optimal for
Everyone? Inter-individual Variation in Caffeine Ergogenicity, and a Move Towards
Personalised Sports Nutrition. Sports Med. (2018)
9. ^ Jenkins NT, et al. Ergogenic effects of low doses of caffeine on cycling performance. Int J
Sport Nutr Exerc Metab. (2008)
10. ^ Jay R Hoffman, Alyssa Varanoske, Jeffrey R Stout. Effects of β-Alanine Supplementation
on Carnosine Elevation and Physiological Performance. Adv Food Nutr Res. (2018)
11. ^ Everaert I, et al. Vegetarianism, female gender and increasing age, but not CNDP1
genotype, are associated with reduced muscle carnosine levels in humans. Amino Acids.
(2011)
12. ^ Alan R Hipkiss. Glycation, ageing and carnosine: are carnivorous diets beneficial?. Mech
Ageing Dev. (2005)
13. ^ Gariballa SE, Sinclair AJ. Carnosine: physiological properties and therapeutic potential.
Age Ageing. (2000)
28
Probiotics for celiac disease
 Tags: Celiac, Probiotics, Meta-analysis, Gut Health, Microbiome, Supplementation
 Study under review: Probiotics for Celiac Disease: A Systematic Review and Meta-Analysis of
Randomized Controlled Trials

This study addressed the question of how probiotic supplementation affects gastrointestinal symptoms
and quality of life in people with celiac disease (CD).

Celiac disease (CD), which affects about 1% of the entire population[1], is often managed by eliminating
or drastically reducing exposure to gluten. A complete removal of gluten can often be difficult, so there is
a need for additional, adjuvant type therapies for improving the symptoms associated with CD. CD is an
autoimmune disease that affects the small intestine, thus there has been a growing interest in targeting
the microbiome as a potential therapeutic intervention over the last several decades.
In previous research, altered microbiomes[2] have been found in people with CD, compared to people
without CD. Several studies have found that levels of some common strains of bacteria, such as
Faecalibacterium prausnitzii[3] and Bifidobacterium longum[4], are lower in people with CD. There have
been randomized trials[5] and investigational studies in mice[6] that have examined probiotic-based
interventions designed to address some of these altered microbiome states. The results of these studies
have been mixed, with no consistent signal present. Furthermore, the precise mechanisms by which
these interventions work has also not yet been fully elucidated. As such, researchers conducted a
systematic review and meta-analysis of randomized controlled trials to evaluate the efficacy of probiotics
on improving gastrointestinal symptoms and quality of life for people with CD.
There are very few therapeutic options for people with CD outside of adopting a gluten free diet.
Altered microbiomes have been observed in humans with CD and probiotic therapies have been
investigated. This study was a systematic review and randomized trial examining the effect of
29
probiotic supplementation on gastrointestinal symptoms and quality of life among people with
CD.

The researchers aimed to determine the efficacy of probiotic treatments for CD by conducting a
systematic review and meta-analysis of data from randomized controlled trials in adults and children
with CD. The included studies consisted of people with CD diagnosed based on serology[7] and confirmed
duodenal biopsies[8] (Marsh score of at least 3). The probiotic interventions included probiotics of any
type and dose, administered orally for at least two weeks. The study was registered on PROSPERO.
The meta-analysis ultimately included seven studies from six randomized controlled trials with a total of
279 participants. Four trials included adults, while two trials included children. Only two trials utilized
the same probiotic strains and dosages, but all studies did include a placebo. Participants were required
to be on a gluten free diet for at least six months prior to enrollment and were excluded if they were on
immunosuppressive therapy. The outcomes of interest in this study are based upon gastrointestinal
symptoms, quality of life, inflammation, intestinal permeability, and changes in the microbiome (Figure
1). The study adhered to PRISMA guidelines and the risk of bias was assessed using the Cochrane risk of
bias tool.
Figure 1: How the different effects were measured
Domain Measures
Gastrointestinal Binary outcome (improved or not improved) as assessed by the Irritable Bowel
symptoms Syndrome Severity Scoring System (IBS-SSS).
Improvement as assessed by the GSRS, Celiac Symptom Index, and the Celiac
Disease Questionnaire Gastrointestinal Subscore
Quality of life Celiac Disease Questionnaire Quality of Life Subscore
Irritable Bowel Syndrome Quality of Life Questionnaire.
Safety Adverse events
Inflammation Changes in serum levels of tumor necrosis factor-α
30
Domain Measures
Intestinal Lactulose/mannitol ratio

permeability
Microbiome Changes in fecal microbiota
This study was a meta-analysis of seven randomized trials examining the effects of gradual and
rapid weight loss in adults with overweight and obesity in the context of similar weight loss
between groups. The study examined differences in outcomes for fat mass, fat free mass, body fat
percentage, resting metabolic rate, bodyweight, BMI, hip circumference, waist circumference, and
waist-to-hip circumference.

When compared to placebo, probiotic supplementation improved gastrointestinal symptoms, but only
when assessed by the GI Symptoms Rating Scale. As shown in Figure 2, when all assessments looking at
continuous symptom measurements were pooled together, this effect was washed out and there was no
statistically significant benefit of probiotic supplementation.
The study also attempted to meta-analyze studies that looked at recovery as a binary (“on-off;” either
they recovered or they didn’t) variable. Three of the seven studies reported binary outcomes, but only
one of them provided a validated measure of gastrointestinal symptoms. The others had more informal
symptom assessments. As such, only the single study[9] with the validated measure was “meta-analyzed,”
so to speak, though it’s not actually possible to meta-analyze a single study. Its findings, along with some
details related to this single study, are also shown in Figure 2.
There was no benefit found for self-reported diarrhea after treatment with probiotics. Furthermore, there
were no differences between groups for adverse events. There was substantial heterogeneity between
studies, which was due primarily to differences in probiotic type and geographical location, as well as if
participants were also diagnosed with irritable bowel syndrome.
31
Figure 2: Main outcomes of the meta-analysis
Analysis Outcome Number of Quality Anything else of note?

studies and
participants
Studies that Approximately One, with The single study Participants were on a
reported 75% relative 109 was at low risk gluten-free diet for two years,
dichotomous risk reduction participants of bias, but the but still had symptoms.
outcomes quality of the
(did people analysis was The probiotic was a mix of
improve or low since it was specific strains of
not?) only one study Lactobacillus casei,
Lactobacillus plantarum,
Bifidobacterium animalis,
and Bifidobacterium breve
dosed at 4x1010 CFU for six
weeks
GSRS Approximately Two, with a The analysis

reduction 29% reduction total of 131 was of low
in symptoms participants quality, with
studies being at
high risk of bias
All studies No Four, with a The analysis

that statistically total of 197 was of very low
measured significant participants quality
symptoms effect
reduction
Probiotics did not improve quality of life in either of the two studies that assessed quality of life. There
was also no effect of probiotics on inflammation or intestinal permeability. There was an effect on the
microbiome, with probiotics increasing bifidobacteria species. However, the change in bifidobacteria was
measured via feces, which is reflective of the microbiome of the colon, not necessarily the site of disease.
Additionally, the effect of probiotics on bifidobacteria species was greater among adults than children
and among people who adhered to gluten free diets for longer than one year.
32
Overall, the evidence for these outcomes was weak due to small sample sizes, high heterogeneity, and a
relatively high risk of bias on the whole.
Probiotic supplementation may improve gastrointestinal symptoms, and increase the amount of
bifidobacteria species among adults and children with CD. However, the evidence is weak since
there were only a handful of small studies, there was no difference in GI symptoms after
probiotics when different questionnaires were pooled, and the results are at a high risk of bias.

The study under review examined data across seven studies that included six randomized controlled
trials and found that probiotic supplementation may improve gastrointestinal symptoms and increase
bifidobacteria species in children and adults with CD. However there was a high risk of bias across
several domains in the trials, sample sizes were small, there were very few studies included for each
outcome, and there was a lack of consistency with the dosages and probiotic strains used. As such, the
present results should be interpreted with extreme caution.
There are other aspects of how the microbiome and probiotics may affect people with CD. Bifidobacteria
is a broad category of bacteria, different strains of which have been found to have profoundly different
effects in the context of gluten. For example, in studies of the microbiome of people with and without CD,
different strains of bifidobacteria exist[10]. Of those different strains, some are actually able to break
down gluten proteins, while others are not[10]. How much this matters is still an open question, but
there’s some preliminary evidence[11] to suggest that having a microbiome able to degrade gluten
components could play a role in CD development. It is still unclear exactly what type of dysbiosis is most
reflective of people with CD, as some studies show that bifidobacteria diversity is higher[12] among
people with CD, while others point toward lower total amounts of bifidobacteria[2]. There are also other
types of bacteria that need to be considered, not just bifidobacteria, such as lactobacillus[13], bacteroides
[12], staphylococcus[14], and E. coli[15], which may also be different in people with CD compared to those
without CD.
The complexity of the microbiome and its unclear connection to CD, along with the substantial
limitations of the present study, make it difficult to draw any meaningful conclusions about the effect of
probiotic supplementation in the context of improving the symptoms associated with CD. Furthermore,
CD occurs in the small intestine, and the large majority of the human microbiome is found in the large
intestine. It is unclear exactly how the microbiome affects CD, given the difference in locations of disease
and presence of the microbiome.
33
The findings of the present study should be interpreted with caution, as there are methodologic
issues that reduce the confidence that can be placed in the present findings. Furthermore, the
precise mechanisms by which the microbiome affects the symptoms associated with CD are not
well understood.

This study suggests that probiotic supplementation may have some benefit for gastrointestinal
symptoms associated with CD and may increase bifidobacteria species count in the microbiome of
people with CD without any major risk of adverse events. However, there was no observed effect on
diarrhea, quality of life, inflammation, or intestinal permeability.
These results should be interpreted with a high level of caution, as the studies included in this analysis
had small sample sizes, had moderate to high risk of bias, and the interventions used different in dosage
and probiotic type. Furthermore, it is not yet fully understood how the microbiome is involved in CD or
how it may affect the symptoms associated with CD.
What’s your take on the state of the research? Have your say over at the NERD Facebook forum.
 References
1. ^ Singh P, et al. Global Prevalence of Celiac Disease: Systematic Review and Meta-
analysis. Clin Gastroenterol Hepatol. (2018)
2. ^ a b Maria Carmen Collado, et al. Imbalances in faecal and duodenal Bifidobacterium
species composition in active and non-active coeliac disease. BMC Microbiol. (2008)
3. ^ Inmaculada Nadal, et al. Imbalance in the composition of the duodenal microbiota of
children with coeliac disease. J Med Microbiol. (2007)
4. ^ Lisléia Golfetto, et al. Lower bifidobacteria counts in adult patients with celiac disease
on a gluten-free diet. Arq Gastroenterol. (Apr-Jun)
34
5. ^ Marta Olivares, et al. Double-blind, randomised, placebo-controlled intervention trial to
evaluate the effects of Bifidobacterium longum CECT 7347 in children with newly
diagnosed coeliac disease. Br J Nutr. (2014)
6. ^ José Moisés Laparra, et al. Bifidobacterium longum CECT 7347 modulates immune
responses in a gliadin-induced enteropathy animal model. PLoS One. (2012)
7. ^ Mohsin Rashid, Jennie Lee. Serologic testing in celiac disease: Practical guide for
clinicians. Can Fam Physician. (2016)
8. ^ B C Dickson, C J Streutker, R Chetty. Coeliac disease: an update for pathologists. J Clin
Pathol. (2006)
9. ^ Ruggiero Francavilla, et al. Clinical and Microbiological Effect of a Multispecies Probiotic
Supplementation in Celiac Patients With Persistent IBS-type Symptoms: A Randomized,
Double-Blind, Placebo-controlled, Multicenter Trial. J Clin Gastroenterol. (2019)
10. ^ a b Alberto Caminero, et al. Diversity of the cultivable human gut microbiome involved
in gluten metabolism: isolation of microorganisms with potential interest for coeliac
disease. FEMS Microbiol Ecol. (2014)
11. ^ D Bernardo, et al. Is it true that coeliacs do not digest gliadin? Degradation pattern of
gliadin in coeliac disease small intestinal mucosa. Gut. (2009)
12. ^ a b Ester Sánchez, et al. Intestinal Bacteroides species associated with coeliac disease. J
Clin Pathol. (2010)
13. ^ María J Lorenzo Pisarello, et al. Decrease in lactobacilli in the intestinal microbiota of
celiac children with a gluten-free diet, and selection of potentially probiotic strains. Can J
Microbiol. (2015)
14. ^ Ester Sánchez, et al. Duodenal-mucosal bacteria associated with celiac disease in
children. Appl Environ Microbiol. (2013)
15. ^ Marta Olivares, et al. Increased prevalence of pathogenic bacteria in the gut microbiota
of infants at risk of developing celiac disease: The PROFICEL study. Gut Microbes. (2018)
35
Nerd Nulls: September-October 2020
 Tags: NERD Nulls
Here’s a very quick summary of some randomized controlled trials (RCTs) and meta-analyses of RCTs that
were published in September and October of 2020 and didn’t find evidence of an effect. This is known as
a null effect.
Keep the following in mind when interpreting a null effect:
While one study can provide evidence that something doesn’t work, it doesn’t prove it.
Similar, repeatable results from multiple studies make for stronger evidence, whether the
finding is positive or negative.
Not all null effects are the same. A meta-analysis of low-quality studies or a small clinical
trial usually won’t provide strong evidence, whether the finding is positive or negative.
The population matters. For instance, the lack of an effect in healthy young people
doesn’t necessarily mean that an intervention wouldn’t work in people who are older and
have a specific health condition.
Cancer
Omega-6 fatty acid blood levels don’t affect pancreatic cancer risk one way or the other[1]
What was studied? How genetic factors that influence omega-6 fatty acid blood levels are associated
with pancreatic cancer risk.
Why study it? Omega-6 fatty acids, especially arachidonic acid, have been found to promote pancreatic
cancer growth in test tube studies. Furthermore, some, but not all, observational studies have found an
association between omega-6 fatty acid intake and pancreatic cancer risk.
What was(n’t) found? Genetic markers that naturally boost omega-6 fatty acid blood levels had
practically no influence on the risk of developing pancreatic cancer, either positively or negatively. This
implies that blood levels of omega-6 fatty acids from dietary or supplementary sources also won’t affect
pancreatic cancer risk much.
36
How null was it? Quite null. The sample size was large, all measures were very close to zero, and the
genes the authors chose accounted for a lot of change in omega-6 fatty acid levels, suggesting that the
genes were well chosen.
Cardiovascular disease
Supplementing vitamin D or omega-3 fatty acids before a stroke didn’t clearly help with outcomes in
people who had strokes[2]
What was studied? Data from the VITAL trial was analyzed to determine if supplementing with 2,000 IU of
vitamin D or 1 gram of omega-3 fatty acids before having a stroke improved stroke outcomes afterward.
Why study it? People with low vitamin D levels who have strokes tend to have worse outcomes, but it’s
unclear if this is correlation or causation. Also, it’s been found that mice on a high omega-3 diet have
improved stroke outcomes, but it’s unclear if this effect carries over to humans. Since there’s not much
evidence around how supplementation before a stroke affects outcomes after a stroke, the authors
decided to do a secondary analysis of the VITAL trial to see what they could find.
What was(n’t) found? Supplementation of vitamin D or omega-3s before a stroke didn’t clearly improve
functional limitations or physical disability outcomes after people had a stroke.
How null was it? Due to limited data, the confidence intervals for these results suggest that the evidence
is compatible with a wide range of outcomes. So, while there’s no clear strong effect, more evidence
would be useful, especially for omega-3 supplementation, which was suggestive of a possible benefit,
while vitamin D was less suggestive of a benefit.
Cognition & memory

Sugary drinks didn’t affect cognition, mood, or satiety in the short term[3]
What was studied? The effect of three drinks with different glycemic indices (sucrose, isomaltulose, and
non-caloric sucralose as the control) on measures of cognition, mood, and satiety 60 minutes after
ingesting the beverage.
Why study it? Animal studies have found that boosting blood sugar leads to higher brain activity in areas
related to cognition and memory, but human studies have yielded mixed results. One reason for this may
be due to differences in glycemic response due to the type of sugar used and other meal components.
This study aimed to address these concerns by manipulating glycemic response through the type of
sugar given while the participants were fasting.
37
What was(n’t) found? There was no strong difference between the two caloric sweeteners and the
control drink on any metric of cognition, mood, or satiety.
How null was it? This study was quite small and measured a lot of outcomes, leaving open the possibility
for false negatives. Also, glycemic response was not measured before the cognitive tests because the
researchers thought that the finger prick could affect performance.
Diabetes & blood sugar

Supplementing vitamin D may not lower type 2 diabetes risk in Europeans[4]
What was studied? The relationship between vitamin D levels and the risk of developing type 2 diabetes
was studied in two ways: through meta-analyzing observational studies to look at correlation, and
through Mendelian randomization to explore causation in a large European population.
Why study it? Observational studies suggest that vitamin D levels are correlated with type 2 diabetes risk,
but the limited number of clinical trials that have directly explored the matter haven’t found strong
evidence that vitamin D causes lower risk. The topic has also been studied in previous Mendelian
randomization studies, but with mixed results for two possible reasons: not looking at vitamin D
metabolites, and having weaker predictive genes than currently exist. This study sought to address both
of these problems in its Mendelian randomization analysis.
What was(n’t) found? While a clear association between vitamin D levels and diabetes risk was found by
meta-analyzing observational studies, the Mendelian randomization analysis found no causal link
between any vitamin D levels (or its metabolites) and diabetes risk. This suggests that the link the
observational studies found is correlation, not causation, and that raising vitamin D levels through
supplementation wouldn’t affect type 2 diabetes risk much.
How null was it? The evidence is pretty strong for European populations since that’s the population
involved in the Mendelian randomization study. However, these results may not apply to other
populations.
Herbal supplements
No clear evidence of ginseng’s effect on weight, fat, or waist circumference
What was studied? The effect of Panax ginseng supplementation on weight and other anthropometric
measurements in randomized controlled trials was meta-analyzed.
38
Why study it? The effect of ginseng on anthropometric measurements has been measured in several
studies, but there hasn’t been a meta-analysis of these studies to date.
What was(n’t) found? There was no clear effect of supplementation on weight, waist circumference, or
body fat percentage.
How null was it? Most of the trials to date have been small, heterogeneous, and short-term (under three
months). Longer, larger trials would be useful.
Infants, children & teenagers

Long-chain omega-3 fatty acid supplementation for pregnant or breastfeeding women had no strong
effect on their children’s cognition or birthweight[5]
What was studied? The cognition and birthweight of children whose mothers supplemented fish oil
while pregnant or breastfeeding, through meta-analyzing randomized, controlled trials.
Why study it? The long-chain omega-3 polyunsaturated fatty acids found in fish oil, especially
docosahexaenoic acid (DHA), have been shown to be essential in learning and memory in primate
experiments, and in neuronal development in other animal experiments. However, whether
supplementation will help the cognition of developing human minds is still an open question.
What was(n’t) found? There was no statistically significant effect on any cognitive measure or
birthweight.
How null was it? The result was not strongly null for three big reasons. The first was that most of the
trials were small and had large dropout rates, making it difficult to see even moderate effects in many
cases. Second, supplementation would probably have the greatest effect before 20 weeks of gestation,
but none of the examined trials started supplementation that early (although this is a big logistical
challenge and would be hard to do practically). Finally, while there were no statistically significant effects
observed, the 95% confidence intervals suggest that the data were mostly compatible with small effects
on attention and birthweight. Thus, there may be some small effect in these two domains.
DHA supplementation didn’t have a big effect on the executive function of school-aged children[6]
What was studied? The effect of 300 milligrams of daily docosahexaenoic acid (DHA) supplementation on
school-aged children’s executive function, which is the ability to exert self-control, shift focus
consciously, and process information.
Why study it? DHA accumulates in parts of the brain that develop rapidly in childhood through mid-
adolescence and are important for executive function. DHA levels in certain parts of the brain have also
39
been found to be associated with stronger brain activation. However, it’s still unclear whether
supplementation with DHA could actually improve functioning in school-aged children.
What was(n’t) found? No effect on any metric of executive function, including cognitive flexibility and
working memory, was found.
How null was it? The trial was well designed and preregistered with a clear primary outcome. However,
the dose may have been too small or the time frame too short to see a clear effect. Confirmation of these
results at higher doses with a wider battery of cognitive tests for confirmation may be helpful.
Zinc supplementation, both with and without iron co-supplementation, has no clear effect on childhood
motor or mental development[7]
What was studied? Randomized controlled trials exploring the effect of zinc supplementation on
development metrics in children up to 5 years old were meta-analyzed.
Why study it? Zinc is important for neuronal development, but about 7.5% of children in high-income
countries and over 50% in lower-income countries may be zinc deficient. However, zinc can lower iron
blood levels because the two elements interfere with each others’ absorption.
What was(n’t) found? No measure of childhood motor or mental development was strongly affected by
zinc supplementation, whether or not it was co-administered with iron.
How null was it? The authors were unable to meta-analyze trials in which the children were older than
one year due to major differences between the studies they found. They rated the quality of evidence for
zinc’s effect on children under one year as being low to moderate. However, it was harder to evaluate
zinc’s longer-term impact, although they did assess the longer-term data qualitatively and found no
major effect.
Muscle gain & exercise

Leucine supplementation doesn’t help keep muscle on immobilized limbs[8]
What was studied? How 15 grams of leucine supplementation per day for seven days in young, healthy
men affected leg strength and muscle mass when the leg was immobilized.
Why study it? There are mechanistic reasons for thinking that branched-chain amino acids like leucine
could preserve muscle mass during times of immobilization (e.g., after injury or during illness). However,
previous research at half the dose didn’t work in younger men, but higher doses of an amino acid cocktail
containing 12 grams of leucine daily have been found to work. This led the authors to suspect that higher
doses of leucine alone could preserve strength and muscle mass in younger people, too.
40
What was(n’t) found? There was no effect of high-dose leucine supplementation on fat-free mass
preservation or strength in the immobilized leg compared to placebo.
How null was it? This was a somewhat small study involving 16 people. The study was powered to detect
moderate changes in fat-free mass (the study’s primary outcome), but smaller effects cannot be ruled
out. This problem may have been compounded by the use of DXA to measure fat-free mass, which isn’t
quite as precise as MRI or computed tomography.
A shot of nitrate-rich beetroot juice didn’t help with repeated sprint performance[9]
What was studied? How a shot of nitrate-rich beetroot juice containing about 6 mmol of nitrate three
hours prior to sprinting affected performance in ten 40-meter shuttle sprints with 30 seconds of rest in
between each sprint.
Why study it? Nitrate supplementation has been mostly studied in specific activities like cycling and
kayaking. However, there’s less evidence looking at its effect on exercise patterns that carry across
activities, like multiple short sprints.
What was(n’t) found? While plasma nitrate levels were boosted six-fold in the nitrate-rich condition
compared to placebo, there was no clear effect on sprint time or performance degradation over time.
How null was it? The study was relatively small (involving 16 men) and didn’t involve a power
calculation, leaving the possibility of whether or not this is a false negative open to question.
Outside the box

Vitamin D plus omega-3s don’t help much with AMD[10]
What was studied? How 2,000 IU of vitamin D3 and 1 gram of omega-3 fatty acids daily for over five years
affected development of age-related macular degeneration (AMD; a progressive disease involving the
retina in the eye that can lead to severe vision loss) or its progression in people who already had it.
Why study it? Observational evidence has found that people with lower blood levels of vitamin D or
omega-3s may be at higher risk of AMD. However, there’s little experimental evidence addressing
whether supplementation could help.
What was(n’t) found? Neither vitamin D nor omega-3 supplementation helped prevent AMD from
occurring or progressing.
How null was it? This was a preplanned secondary study stemming from the VITAL trial. And even though
the trial had a huge sample size and lasted years, there weren’t many AMD events that occurred. This led
41
to pretty wide uncertainty in how helpful supplementation could be. The evidence from this study is
roughly compatible with a 20–30% increase or decrease in AMD risk with supplementation. So, while this
study provides solid evidence that huge effects don’t exist, the evidence it provides is compatible with
smaller risk reductions (or increases!).
Pain, joints & bones

Adding MK-7 to calcium and vitamin D didn’t improve bone health in postmenopausal women[11]
What was studied? Postmenopausal women with osteopenia were all given about 1,500 IU of vitamin D3
and 800 milligrams of calcium daily for three years. They were also randomized to either placebo or 375
mcg MK-7 (a type of K2 vitamin) on top of the first two supplements. Bone mass, structure, and markers
of bone turnover were measured.
Why study it? While calcium and vitamin D supplementation is recommended by the World Health
Organization for people with osteopenia and osteoporosis, studies looking at MK-7’s effect on bone mass
have been less clear, warranting a longer-term study.
What was(n’t) found? Bone mineral density at several sites declined to roughly the same extent in the
MK-7 and placebo groups. Bone turnover markers also weren’t clearly different between the two groups.
Bone microstructure was better in the MK-7 group at one year after supplementation, but not at three
years.
How null was it? This study was originally planned for one year, but was extended when a Dutch study
using a lower dose (180 mcg) of MK-7 found improved bone density after three years and the researchers
wanted to see if they could replicate the results. The sample size of the Dutch study was larger, which
could explain why it found results, while this study did not. The women in the Dutch study also had a
higher average starting bone mineral density and were younger on average (60, compared to 67 in this
study).
Vitamins & minerals

Vitamin K[12]2[12] didn’t help boost bone mass or reduce arterial calcification in people with diabetes[12]
What was studied? The effect of 360 mcg of vitamin K2 daily for six months on slowing bone loss and
arterial calcification (arteries hardening due to calcium buildup) in people with diabetes and
cardiovascular disease.
42
Why study it? People with diabetes have an increased risk of fractures and calcification, so finding ways
to reduce the risk of these processes in people with diabetes would be helpful. Two proteins in the body
could slow down these processes: Matrix Gla protein and osteocalcin. Both of these require vitamin K to
be fully functional, though. This suggests that vitamin K supplementation, especially vitamin K2 which
lasts longer in the body and is absorbed more than vitamin K1, could be beneficial.
What was(n’t) found? Vitamin K2 supplementation did not slow bone density loss from the spine or slow
arterial calcification in major arterial beds compared to placebo in people with diabetes and
cardiovascular disease.
How null was it? Somewhat, but follow-up would be useful since this was a small study of 68 people. It
was also a secondary analysis of a previous study designed to test the effects of supplementation on
femoral artery calcification, as opposed to calcification of several arterial beds. Secondary analyses
normally should have less confidence placed in them, but confidence in this finding is bolstered a bit
since the original study found little evidence of an effect on calcification and this analysis was pre-
planned. It’s also possible that future studies involving participants with more severe vitamin K
deficiency may find an effect.
Low-quality evidence suggests vitamin D supplementation doesn’t clearly improve blood lipids in people
with the metabolic syndrome[2]
What was studied? Trials measuring blood lipids in people with the metabolic syndrome were meta-
analyzed to determine if supplementing with vitamin D affected lipid levels.
Why study it? Low levels of vitamin D have been linked to increased risk and severity of the metabolic
syndrome in observational studies, but the limited number of controlled trials examining the issue
yielded mixed results, warranting a meta-analysis.
What was(n’t) found? There was no clear impact of vitamin D supplementation on lipid levels in people
with metabolic syndrome.
How null was it? Not particularly null. Only seven trials were found, of which four were meta-analyzed.
The authors rated the quality of evidence as low or very low, depending on the outcome. More high-
quality studies are needed to explore this issue.
43
 References
1. ^ Dalia H Ghoneim, et al. Mendelian Randomization Analysis of n-6 Polyunsaturated Fatty

Acid Levels and Pancreatic Cancer Risk. Cancer Epidemiol Biomarkers Prev. (2020)
2. ^ a b Fatme AlAnouti, et al. Effects of Vitamin D Supplementation on Lipid Profile in Adults
with the Metabolic Syndrome: A Systematic Review and Meta-Analysis of Randomized
Controlled Trials. Nutrients. (2020)
3. ^ Qingyuan Deng, et al. Cognitive performance, mood and satiety following ingestion of
beverages imparting different glycaemic responses: a randomised double-blind crossover
trial. Eur J Clin Nutr. (2020)
4. ^ Ju-Sheng Zheng, et al. The association between circulating 25-hydroxyvitamin D
metabolites and type 2 diabetes in European populations: A meta-analysis and Mendelian
randomisation analysis. PLoS Med. (2020)
5. ^ A Lehner, et al. Impact of omega-3 fatty acid DHA and EPA supplementation in pregnant
or breast-feeding women on cognitive performance of children: systematic review and
meta-analysis. Nutr Rev. (2020)
6. ^ Guo-Yi Yang, et al. No effect of 6-month supplementation with 300 mg/d
docosahexaenoic acid on executive functions among healthy school-aged children: a
randomized, double-blind, placebo-controlled trial. Eur J Nutr. (2020)
7. ^ Firoozeh Sajedi, et al. Does zinc with and without iron co-supplementation have effect
on motor and mental development of children? A systematic review and meta-analysis.
BMC Pediatr. (2020)
8. ^ Sophie J Edwards, et al. High-dose leucine supplementation does not prevent muscle
atrophy or strength loss over 7 days of immobilization in healthy young males. Am J Clin
Nutr. (2020)
9. ^ Ciara M E Reynolds, et al. Acute ingestion of beetroot juice does not improve short-
duration repeated sprint running performance in male team sport athletes. J Sports Sci.
(2020)
10. ^ William G Christen, et al. Effect of Vitamin D and ω-3 Fatty Acid Supplementation on
Risk of Age-Related Macular Degeneration: An Ancillary Study of the VITAL Randomized
Clinical Trial. JAMA Ophthalmol. (2020)
11. ^ S H Rønn, et al. The effect of vitamin MK-7 on bone mineral density and
microarchitecture in postmenopausal women with osteopenia, a 3-year randomized,
placebo-controlled clinical trial. Osteoporos Int. (2020)
12. ^ a b c Jonas W Bartstra, et al. Six months vitamin K treatment does not affect systemic
arterial calcification or bone mineral density in diabetes mellitus 2. Eur J Nutr. (2020)
44
Is honey an effective remedy for symptoms of upper
respiratory tract infections?
 Tags: Meta-analysis, Respiratory Tract Infection, Children
 Study under review: Effectiveness of honey for symptomatic relief in upper respiratory tract
infections: a systematic review and meta-analysis
Quick Takes
What was the question? How does honey affect upper respiratory tract infection (URTI)
symptoms?
How was it answered? Researchers conducted a meta-analysis of randomized controlled trials.
Who was studied? Participants included people of all ages with clinically- or laboratory-
diagnosed URTI.
What was the intervention? Participants received honey in any form, administered with or
without other treatments, compared to placebo, usual care, or no treatment.
What's the main takeaway? Honey had a small-to-moderate effect on cough and combined URTI
symptoms compared to usual care, and a moderate effect on combined symptoms compared to
placebo.
Any caveats? These results should be taken lightly because the studies comparing honey
interventions to usual care were of mixed or poor quality. While the study quality in the meta-
analysis comparing honey to placebo was generally good, there were only two studies, which isn’t
much data to draw strong conclusions from.

What is the effect of honey on upper respiratory tract infection (URTI) symptoms?
45
URTI is an umbrella term used to describe infections of the upper respiratory tract (which includes the
nose, sinuses, and throat) that commonly involve symptoms like coughing, a sore throat, nasal
congestion, runny nose, and sneezing.
Most URTIs are caused by viruses, as opposed to bacteria, which means that treatment with antibiotics is
ineffective. As such, usual care for URTIs focuses primarily on temporary symptom relief through the use
of medications like decongestants, antihistamines, analgesics, and antitussives (i.e., cough
suppressants). Beyond these conventional therapies, alternative and complementary[1] therapies are
also being explored. The results of one review article evaluating some of these therapies’ efficacy for one
major URTI, the common cold, is laid out in Figure 1. Another such therapy is honey.
Figure 1: The efficacy of some nonpharmacological options for preventing and treating the common cold
Intervention Authors' Other notes or updates

assessment
of benefit
Hygiene (e.g. Likely

handwashing) and beneficial
physical
prevention (e.g.,
masks)
Zinc Likely The cited study examined meta-analyses on 10–15 mg zinc

supplementation beneficial sulfate tablets in children. Since the publication of this
review, zinc acetate lozenges have[2] been shown to be
effective in adults.
Probiotics May be A Cochrane review[3] suggests the evidence quality is low to

beneficial very low.
Gargling Unclear
benefit for
water, no
46
Intervention Authors' Other notes or updates
assessment
of benefit
benefit from
iodine
Ginseng Unclear
benefit
Exercise Unclear
benefit
Reference: Allan et al. CMAJ. 2014 Feb.[4]
Although honey has a long history of use as a home remedy to treat symptoms of URTIs, there is currently
little scientific evidence to support its use. While a 2018 Cochrane systematic review[5] found some
evidence that honey may relieve cough in children, the authors of the review rated the available evidence
as low to moderate quality, and concluded that there was no strong evidence for or against using honey.
However, the effect of honey on other URTI symptoms and in adult populations was not examined. As
such, the goal of the study under review was to conduct a meta-analysis of the effects of honey on URTI
symptoms in people of all age groups.
While usual care for URTIs focuses primarily on temporary symptom relief through the use of
medications, alternative and complementary therapies are also being explored. One such therapy
is honey. The study under review is a meta-analysis that investigated the effects of honey on
upper respiratory tract infection (URTI) symptoms in people of all age groups.

The authors conducted a systematic review and meta-analysis of randomized controlled trials that
looked at the effects of honey on URTI symptoms in people of all age groups with clinically or laboratory-
diagnosed URTI symptoms. The honey could be of any type, and administered in any way, alone or
together with other treatments, and the control group could be placebo, no treatment, or usual therapy.
Ultimately, 12 trials were included in the meta-analysis, of which eight were in children or adolescents,
and four were in adults. Eight trials used pure honey, three trials used syrups containing honey and plant
47
complexes or herb extracts, one trial used honey mixed with milk, and one trial used honey mixed with
coffee. The reason these trials add up to 13 is that one trial included two treatments: a honey-only
treatment and a honey plus coffee treatment. The types of comparators included placebo and usual care,
the latter including diphenhydramine, dextromethorphan, carbocysteine, combinations of different
medications, and, strangely, coffee.
Assessed outcomes included cough frequency and severity, and combined symptom score. Separate
meta-analyses were performed for different comparators (i.e., placebo and usual care). Outcome data
were summarized in a random-effects model.
The researchers tested heterogeneity using the I2 statistic, and assessed the risk of bias of the included
trials with the Cochrane Collaboration’s risk of bias assessment tool for RCTs, where bias was assessed as
high, low, or unclear over six domains: selection, performance, detection, attrition, reporting, and other.
Funnel plots to assess publication bias could not be used due to the small number of studies. The meta
analysis was preregistered, and followed PRISMA guidelines.
This was a systematic review and meta-analysis of 12 randomized controlled trials that examined
the effects of honey (of any type, and administered in any way, alone or together with other
treatments) as compared to placebo, no treatment, or usual care, on URTI symptoms in people of
all age groups.

When compared to usual care, honey improved cough frequency (n=8, SMD=-0.36), cough severity (n=5,
SMD=-0.44), and combined symptom scores (n=3, MD=-3.96), with low heterogeneity detected (0% for
cough frequency and combined symptom scores). Trials included in these analyses had a variable or high
risk of bias.
In the analysis comparing honey to placebo, honey did not have a statistically significant improvement
on combined symptom score, although it was close (n=2, SMD=-0.63, 95% CI: -1.44 to 0.18). There were
high levels of heterogeneity detected between the two trials as well, but both had a low risk of bias.
These possibly positive results are summarized in Figure 2.
All of the results above (i.e., for honey vs. usual care, and honey vs. placebo) remained largely unchanged
in the analyses that excluded interventions that used syrups, and honey mixed with milk or coffee.
In the one adult-only analysis (n=4) that could be performed, honey was not better than usual care for
improving cough frequency.
48
Figure 2: Possibly positive meta-analytic results and data assessment
Symptom Number Risk of bias Heterogeneity

of trials
Improved cough frequency 8 Variable Low
Improved cough severity 5 Variable Low
Reduced combined symptom score 3 High Low

(compared to usual care; in children only)
Possibly reduced combined symptom 2 Low (but see the next High
score (compared to placebo) section for some
caveats)
The findings of this meta-analysis indicate that honey improves cough frequency, cough severity,
and combined symptom scores when compared to usual care. However, most trials included in
these analyses were of variable or high risk of bias. Also, only a handful of trials were included in
the analyses, with four trials performed in adults, and just two comparing honey to placebo.

Some strengths of this meta-analysis are that it was preregistered and PRISMA-compliant, it employed a
comprehensive search strategy without language or date restrictions, and that it assessed risk of bias
with the Cochrane Collaboration’s risk of bias assessment tool. The fact that the authors used a random-
effects model (which is more appropriate for trials that aren’t direct replications of one another) to
summarize the data, even in analyses in which heterogeneity[6] was low, was also a plus. There are,
however, some limitations worth addressing.
First, eight of the 12 trials included in the meta-analysis were assessed as being of unclear or high risk of
bias in at least three out of the six domains of the risk of bias assessment tool. Specifically, in the
individual analyses comparing honey to usual care, there was roughly an equal mix of trials of a low and
high risk of bias for the outcome of cough frequency, while for cough severity and combined symptom
score, most trials were of a high risk of bias. This reduces confidence in these results. On the other hand,
in the analysis comparing honey to placebo for combined symptom score, the trials included were
assessed as being of low risk of bias.
49
With the above said, the risk of bias in some of the trials may have been incorrectly assessed. For
example, although two[7] trials by the same research group were assessed as having a low risk of bias for
random sequence generation, (i.e., the process of randomly allocating participants to a group) these
trials did not sufficiently describe the randomization process. This means that they should have been
assessed as having an unclear risk of bias for this domain, and suggests there should be some skepticism
about the overall results of the risk of bias analysis.
Second, most of the analyses only included a small number of trials. Specifically, in the analyses
comparing honey to usual care, there were five trials for cough severity, and only three trials for
combined symptom score. Moreover, just two trials were included in the analysis comparing honey to
placebo, while four trials were included in the analysis restricted to adults. Overall, the small number of
trials in most of the analyses decreases confidence in the results.
Third, and relevant to what was said above: although the researchers intended to use funnel plots to
assess publication bias, due to the small number of trials included in the meta-analysis, they ended up
not doing so. Considering that trials with positive findings are more likely[8] to be submitted and
published than trials with negative or null findings, the absence of a publication bias assessment reduces
confidence in the results of the meta-analysis.
Fourth, the relatively broad eligibility criteria resulted in considerable variability in some aspects of the
trials. For example, the treatments included several different types of honey, combinations of honey with
other ingredients, and administration methods. Also, there were several different comparators in the
“usual care” analyses, with coffee strangely considered as a type of usual care. Despite this, the results
remained largely unchanged in the analyses that excluded the interventions that did not use pure honey,
which is reassuring, as is the finding that there were low or zero levels of heterogeneity in most of the
analyses. However, it should be noted that it is difficult to get a sufficient estimation of heterogeneity in
meta-analyses with a small number of trials, such as the one under review. This, together with the
considerable variability in some methodological aspects of the trials, suggests some skepticism is
warranted related to the levels of heterogeneity detected.
Although the researchers tried to include trials with a variety of URTI symptoms, most trials only
measured cough frequency and severity. Even the combined symptom score outcome only combined
cough-related measures. This means that, although the initial intention of the researchers was to assess
the effect of honey on several URTI symptoms, the results of the meta-analysis only relate to coughing,
and cannot be generalized to all URTI symptoms.
Finally, it’s worth pointing out that, while the results using placebo as a comparator suggest that honey is
not effective for improving URTI symptoms, it could be that honey “works” because of its texture (i.e., by
forming a soothing mechanical barrier on the throat lining), and the placebos worked equally well
50
because of their similarity in texture to honey. However, this is merely speculation. Also, only two trials
were included in the honey vs. placebo analysis, which decreases confidence in these results.
The results of this meta-analysis suggest that, compared to usual therapy, honey improves cough
frequency and severity in children and adolescents with URTIs. However, these results are mostly
based on a handful of trials, most of which are at a high risk of bias.

This meta-analysis suggests that, in children and adolescents with clinically or laboratory-diagnosed
URTI symptoms, honey, as compared to usual care, improves cough frequency and severity. However,
these results are based on only a handful of trials, most of which were found to be at a high risk of bias,
and, as such, should be considered with skepticism.
Hone-y your research reviewing skills by joining the discussion in the private NERD Facebook
forum!
 References
1. ^ Roxane R Carr, Milap C Nahata. Complementary and alternative medicine for upper-
respiratory-tract infection in children. Am J Health Syst Pharm. (2006)
2. ^ Hemilä H, et al. Zinc acetate lozenges for treating the common cold: an individual
patient data meta-analysis. Br J Clin Pharmacol. (2016)
3. ^ Hao Q, Dong BR, Wu T. Probiotics for preventing acute upper respiratory tract
infections. Cochrane Database Syst Rev. (2015)
4. ^ G Michael Allan, Bruce Arroll. Prevention and treatment of the common cold: making
sense of the evidence. CMAJ. (2014)
51
5. ^ Olabisi Oduwole, et al. Honey for acute cough in children. Cochrane Database Syst Rev.
(2018)
6. ^ DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. (1986)
7. ^ Mohammad Ali Raeessi, et al. Honey plus coffee versus systemic steroid in the
treatment of persistent post-infectious cough: a randomised controlled trial. Prim Care
Respir J. (2013)
8. ^ Sally Hopewell, et al. Publication bias in clinical trials due to statistical significance or
direction of trial results. Cochrane Database Syst Rev. (2009)
52
Deep Dive: Does supplementing the sunshine vitamin
impact colorectal cancer outcomes?
 Tags: Vitamin D, Supplementation, Colorectal, Cancer, Meta-analysis
 Study under review: The effect of vitamin D supplementation on survival in patients with
colorectal cancer: systematic review and meta-analysis of randomised controlled trials
Quick Takes
What was the question? Does supplementing vitamin D improve outcomes in
people with colorectal cancer?
How was it studied? Researchers conducted a systematic review and meta-

analyses of randomized controlled trials of vitamin D supplementation, either in
people who already had colorectal cancer, or who developed it during a trial.
Who was studied? Participants included people with colorectal cancer.
What was the intervention? Participants supplemented vitamin D3. Dosages

ranged from 400 IU per day to 100,000 IU every four months.
What’s the main takeaway? Supplementation with vitamin D led to fewer cancer-
related deaths and increased progression-free survival among participants with
colorectal cancer.
Any caveats? There are a limited number of randomized trials examining the effect
of vitamin D in people with colorectal cancer. The present data warrant larger
trials focused on vitamin D supplementation among people with colorectal cancer.
Introduction
Colorectal cancer affects up to 1.8 million[1] people each year and it is responsible for roughly 850,000
deaths[1] worldwide. There appears to be at least some environmental components[2] to colorectal
cancers, as there are major differences in incidence rates based on geographical locations and
53
socioeconomic strata. One hypothesis for the substantial differences in incidence rates is that vitamin D
may play a role in the development and progress of several cancers, including colorectal cancers.
There is data linking vitamin D to colorectal cancer. For example, an observational study found that there
is an inverse correlation[3] between colorectal cancer incidence rates and sunlight exposure by
geographical location. Mechanistically, cultured colon cancer cells[4] divide at a slower rate when treated
with vitamin D, compared to when they’re untreated. However, not all research has produced supporting
evidence. For example, a Mendelian randomization study did[5] not show a clear causal impact of blood
25-hydroxyvitamin D level on CRC risk. Furthermore, several studies have reported that supplementation
with vitamin D does not reduce the risk of developing cancer[6], including colorectal cancer[7]. In addition
to prevention, there have been several randomized trials examining the effect of vitamin D
supplementation on the progression of already established colorectal cancer. The present study was
systematic review and meta-analysis of randomized controlled trials examining the effect of vitamin D
supplementation not on incidence of colorectal cancer, but on the survival and progression of disease in
participants who had already developed it.
Vitamin D has been linked to colorectal cancer through observational and mechanistic research.
Recently, several randomized trials have investigated the role of vitamin D supplementation on
slowing disease progression and improving survival among people with colorectal cancer. The
present study was a systematic review and meta-analysis of randomized controlled trials
examining the effect of vitamin D supplementation on disease progression and survival among
people with colorectal cancer.
What was studied?

The study under review was a systematic review and meta-analysis of randomized controlled trials
examining the effect of vitamin D supplementation on colorectal cancer survival outcomes. The study
utilized PICO[8] inclusion criteria and was registered through PROSPERO. Case studies, reviews, and prior
meta-analysis were excluded.
This study included randomized controlled trials in adults (18 years or older) with or without colorectal
cancer at baseline that had a vitamin D and comparator group (placebo or lower dose of vitamin D), and a
survival outcome. The primary outcome for this analysis was trial level meta-analysis of supplementation
and a composite outcome of colorectal cancer survival outcomes, described in Figure 1. Secondary pre-
specified subgroup meta-analyses were individually performed for colorectal-specific survival, disease
free survival, and for colorectal cancer and population trials.
54
Figure 1: Definitions of types of outcomes explored by the studies used in this meta-analysis.
Type of survival Explanation
Progression-free Includes people who do not progress to a more advanced form of

survival colorectal cancer.
Disease-free survival Includes people who did not die specifically from colorectal cancer.
Overall survival Includes people who did not die from any cause.
Publication and selection bias was investigated through funnel plots and Egger’s regression test.
Heterogeneity between trials and its overall effect on the analysis was assessed using the I2 test. Overally,
heterogeneity and risk of publication bias was low. Sensitivity analyses were also performed to examine
the robustness of the findings.
The study included just five randomized controlled trials and 815 participants. Two trials examined
vitamin D supplementation and mortality among colorectal cancer patients (one trial included any
digestive tract cancer), while a total of three trials examined vitamin D supplementation and colorectal
cancer progression-free survival among cohorts that did not have colorectal cancer at baseline.
The study under review was a systematic review and meta-analysis and meta-regression of five
randomized trials of survival among participants with colorectal cancer. The analysis examined
progression-free survival, disease-specific survival, and overall survival. Publication bias and
heterogeneity were also assessed.

As shown in Figure 2, each of the five trials included in the analysis trended toward a benefit of vitamin D
supplementation on survival outcomes in people with colorectal cancer, although the effect was only
statistically significant in one trial. However, when the results were combined, the pooled effect was
statistically significant and suggested that vitamin D supplementation reduced the composite primary
survival outcome by 30%. Among the people with colorectal cancer at baseline, the risk of disease
progression or death was reduced by 35%. Among the population trials, disease-specific survival was
improved by 24%.
Figure 2: Main results from the meta-analysis (with 95% confidence intervals)
55
Outcomes were similar between trials, with a very small I2 of 0.85%. Furthermore, the funnel plots and
Egger’s test did not reveal significant evidence of publication bias.
Vitamin D supplementation reduces the risk of disease progression and death among people with
colorectal cancer. These findings extend to studies that focus exclusively on people with
colorectal cancer as well as population studies.
The bigger picture

The present data point to vitamin D being a beneficial intervention for improving outcomes among
people with colorectal cancer. Importantly, these findings occur despite varying dosages, lengths of
follow up (ranging from approximately two years to seven years), and different baseline levels of vitamin
D. As such, these data suggest that vitamin D supplementation may play a beneficial role in the
management of colorectal cancer across a broad range of scenarios.
56
These data support a previous meta-analysis[9], which reported that vitamin D supplementation reduced
the risk of cancer mortality by 12%, but did not reduce the risk of developing cancer. It is also supported
by an additional meta-analysis[10] that was done in mostly elderly adults, which also found a reduction in
cancer mortality of 12% and a reduction in total mortality of 7%. This concordance with previous studies
is of interest because the present study excluded trials of small size (no more than 10 participants with
outcomes) and/or short term (no more than one year of follow-up), while the earlier ones did not.
Furthermore, the magnitude of the effects were similar: 13% reduction, compared to 12% reduction, in
cancer mortality, and 7% in both data sets for total mortality. In contrast with these findings, another
meta-analysis[11] did not find a statistically significant reduction in cancer mortality, but the magnitude
of their estimate was very similar, at 15% reduction in risk. A recent randomized trial, the VITAL[12] trial,
found that vitamin D supplementation reduced the risk of developing advanced cancers by about 17%
over placebo. When stratified by BMI, this risk reduction was about 38% among people with normal BMI
(less than 25) but was not present among people with overweight (BMI of 25 to 30) or obesity (BMI of
more than 30).
Early work done in the 1970s and 1980s hinted at vitamin D playing a potential role in colon cancer
formation. First, an observational study[3] found that rates of colon cancer were highest in areas in the
world where sunlight was the lowest, and vitamin D levels can be expected to be lower than in areas with
higher sunlight. Vitamin D supplementation reduced the risk of colon cancer in mice fed high fat diets[13].
Additionally, a 2011 observational study[14] demonstrated that circulating levels of vitamin D are
associated with a reduced risk of colon cancer.
In support of these early findings, there is also mechanistic evidence to support vitamin D’s role in
reducing colon cancer risk. In vitro, colon cancer cells[4] are less proliferative when treated with vitamin D,
than when untreated. Colon cell proliferation[15] was increased in mice with low vitamin D levels.
Additionally, in vitamin D receptor knockout mice[15], markers of tissue damage, oxidation, and
proliferation were increased. Some possible molecular mechanisms by which vitamin D could reduce
cancer growth are shown in Figure 3.
Figure 3: Possible mechanisms by which vitamin D could affect cancer
57
Reference: Fleet et al. Biochem J. 2012 Jan.[16]
It is important to consider these data in a different context: colorectal cancer onset, or incidence. The
present data suggest that vitamin D may help with disease progression, but do not speak to the potential
role vitamin D may play in disease onset. Observational studies do appear to suggest that higher levels of
vitamin D are associated with a lower risk of developing colorectal cancer[17]. However, randomized
58
controlled trials do not seem to support the idea that vitamin D supplementation lowers incidence rates
of developing colorectal cancer.
There are several limitations of the present study that should be taken into consideration when
interpreting the findings. First, there were a limited number of trials and a small pool of participants.
Second, there is a lack of clarity on the effect that cancer stage, site, or subtype may have on the benefit
of vitamin D and survival and progression. It is also unclear whether changes in plasma levels of vitamin
D correlate with risk reduction. However, despite these limitations, there is a signal that vitamin D
supplementation may improve progression and survival among people with colorectal cancer.
Previous meta-analyses support the current findings and the larger literature base points to
vitamin D supplementation improving colorectal progression and mortality, but maybe not the
onset of colorectal cancer. Mechanistically, vitamin D may slow progression by reducing the
spread of cancerous cells.

Q. What is the optimal dose of vitamin D to take for someone with colorectal cancer?
The precise dose is unclear. However, as shown in Figure 1, there seems to be a dose response effect:
higher doses, up to about 4,000 IU per day, may be more beneficial. For example, in the SUNSHINE[18]
study, 4,000 IU appeared to be more beneficial than 400 IU per day. Most studies in the present analysis
found that 2,000–4,000 IU per day was safe and efficacious.
Q. Can you increase vitamin D levels while on treatment?
There is evidence to suggest that vitamin D supplementation can increase vitamin D levels, even when
someone is undergoing cancer treatment. For example, in one study,[19] vitamin D supplementation
raised vitamin D levels among patients undergoing chemotherapy. Vitamin D levels increased by about
8–9 ng/mL among participants who supplemented with vitamin D, compared to a decrease of about 1–2
ng/mL among people who did not supplement with vitamin D.
What should I know?

This systematic review and meta-analysis indicates that supplementing with vitamin D may improve
progression-free survival and mortality for people with colorectal cancer. These findings are present
among cohorts of people with colorectal cancer as well as studies of people who do not have colorectal
59
cancer at baseline. Supplementing 2,000–4,000 IU of vitamin D per day appears to be in the safe and
effective range.
Do you find these results encouraging, or do you think more research is needed? Have your
evidence-based say over at the NERD Facebook group.
 References
1. ^ a b Bray F, et al. Global cancer statistics 2018: GLOBOCAN estimates of incidence and
mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. (2018)
2. ^ Edward Giovannucci. The epidemiology of vitamin D and cancer incidence and
mortality: a review (United States). Cancer Causes Control. (2005)
3. ^ a b C F Garland, F C Garland. Do sunlight and vitamin D reduce the likelihood of colon
cancer?. Int J Epidemiol. (1980)
4. ^ a b W M Tong, et al. Establishment of primary cultures from human colonic tissue
during tumor progression: vitamin-D responses and vitamin-D-receptor expression. Int J
Cancer. (1998)
5. ^ Yazhou He, et al. Exploring causality in the association between circulating
25-hydroxyvitamin D and colorectal cancer risk: a large Mendelian randomisation study.
BMC Med. (2018)
6. ^ R K R Scragg. Overview of results from the Vitamin D Assessment (ViDA) study. J
Endocrinol Invest. (2019)
7. ^ Wactawski-Wende J, et al. Calcium plus vitamin D supplementation and the risk of
colorectal cancer. N Engl J Med. (2006)
8. ^ Mette Brandt Eriksen, Tove Faber Frandsen. The impact of patient, intervention,
comparison, outcome (PICO) as a search strategy tool on literature search quality: a
systematic review. J Med Libr Assoc. (2018)
9. ^ Keum N, Giovannucci E. Vitamin D supplements and cancer incidence and mortality: a
meta-analysis. Br J Cancer. (2014)
60
10. ^ Bjelakovic G, et al. Vitamin D supplementation for prevention of cancer in adults.
Cochrane Database Syst Rev. (2014)
11. ^ Goulão B, et al. Cancer and vitamin D supplementation: a systematic review and meta-
analysis. Am J Clin Nutr. (2018)
12. ^ Paulette D Chandler, et al. Effect of Vitamin D3 Supplements on Development of
Advanced Cancer: A Secondary Analysis of the VITAL Randomized Clinical Trial. JAMA Netw
Open. (2020)
13. ^ B C Pence, F Buddingh. Inhibition of dietary fat-promoted colon carcinogenesis in rats
by supplemental calcium or vitamin D3. Carcinogenesis. (1988)
14. ^ Sara Gandini, et al. Meta-analysis of observational studies of serum 25-hydroxyvitamin
D levels and colorectal, breast and prostate cancer and colorectal adenoma. Int J Cancer.
(2011)
15. ^ a b E Kállay, et al. Vitamin D receptor activity and prevention of colonic
hyperproliferation and oxidative stress. Food Chem Toxicol. (2002)
16. ^ James C Fleet, et al. Vitamin D and cancer: a review of molecular mechanisms. Biochem
J. (2012)
17. ^ Cem Ekmekcioglu, Daniela Haluza, Michael Kundi. 25-Hydroxyvitamin D Status and Risk
for Colorectal Cancer and Type 2 Diabetes Mellitus: A Systematic Review and Meta-
Analysis of Epidemiological Studies. Int J Environ Res Public Health. (2017)
18. ^ Ng K, et al. Effect of High-Dose vs Standard-Dose Vitamin D3 Supplementation on
Progression-Free Survival Among Patients With Advanced or Metastatic Colorectal Cancer:
The SUNSHINE Randomized Clinical Trial. JAMA. (2019)
19. ^ Marissa B Savoie, et al. Vitamin D Levels in Patients with Colorectal Cancer Before and
After Treatment Initiation. J Gastrointest Cancer. (2019)
61
Deep Dive: Reducing common vertigo with vitamin D
and calcium
 Tags: Vitamin D, Calcium, Vertigo, Supplementation
 Study under review: Prevention of benign paroxysmal positional vertigo with vitamin D
supplementation: A randomized trial
Quick Takes
What was the question? Can supplementation with vitamin D and calcium
prevent the recurrence of benign paroxysmal positional vertigo (BPPV) in people
with low vitamin D levels? BPPV is the most common type of vertigo, characterized
by the vertigo usually being caused by changes in head position.
How was it answered? Researchers conducted a randomized controlled trial in

eight hospitals.
Who was studied? Participants included people with confirmed BPPV following
effective treatment with canalith repositioning maneuvers, a series of specific
head movements that can reposition small particles inside the inner ear that
detect movement.
What was the intervention? The intervention group was given vitamin D3 (400 IU
per day) and calcium carbonate (500 milligrams per day) two times per day for one
year, but only when participant vitamin D levels were less than 20 ng/mL. The
observation group received follow-up visits but did not receive further vitamin D
evaluation or supplementation. There was no blinding except by the people who
assessed the outcomes.
What’s the main takeaway? Following successful treatment of BPPV with canalith
repositioning maneuvers, people with low vitamin D levels (<20 ng/mL)
supplementing vitamin D and calcium may experience a decreased recurrence of
BPPV.
62
Any caveats? A large number of participants did not complete the entire study,
with more participants in the supplementation group dropping out, compared to
the observation group. The intention-to-treat analysis was done on a subset of
participants who completed at least one month of follow-up due to the large
number of participants who dropped out of the intervention arm. There was no
placebo control and no blinding of participants, so the results could be influenced
by the placebo effect. Finally, researchers did not measure vitamin D levels in the
observation group. Taken together, these caveats suggest that the findings from
this study should be viewed skeptically.
Introduction
Benign paroxysmal positional vertigo[1] (BPPV), the most common type of vertigo, is a condition
characterized by brief spinning sensations typically lasting less than one minute. BPPF may also result in
nausea and vomiting. The vertigo is usually brought on by changes in head position, such as when a
person tilts their head backward, bends forward, or gets into or out of bed. The causes of[2] BPPV
episodes are not known. However, they can occur after head trauma, being in a recumbent position for a
long time (e.g., in a hair salon or a dentist office), or from inner ear disorders. Several studies have shown
an increase in incidence of BPPV in elderly people. Episodes of BPPV can be successfully treated with
canalith repositioning maneuvers[3], whose effects are shown in Figure 1. These maneuvers are a series of
head movements that reposition small calcium carbonate particles in the inner ear that help detect
movement. However, recurrences are frequent, with studies citing[4] 1–10 year[5] recurrence[6] rates of
15–56%.
Figure 1: Basic ear anatomy and repositioning of the canalith particles (otoconia)
63
The vestibular labyrinth is an organ in the ear. This organ includes three loop-shaped structures called
semicircular canals. The semicircular canals contain fluid and thin hair-like sensors that monitor the
rotation of the head. The ears also contain otolith organs that monitor the position of the head relative to
gravity. The otolith organs contain calcium carbonate crystals (called otoconia) that make us sensitive to
gravity. BPPV occurs when otoconia shift from the utricle into the semicircular canals and become
trapped there. This makes the semicircular canal sensitive to changes in head position that it normally
would not respond to, resulting in dizzy spells. In the utricle, the otoconia may become loosened and
shift due to an injury, age, or infection.
Studies have shown that people with BPPV have a higher prevalence of vitamin D[7] deficiency or
insufficiency and lower bone mineral density[8] than controls. This may be related to the role of vitamin D
in bone turnover[9] via the regulation of calcium absorption and resulting in impaired calcium
metabolism[10]. A small retrospective pilot study[11] and a small study aiming[12] to detect the effect of
treatment of severe vitamin D deficiency on the recurrence rate of BPPV reported vitamin D
supplementation has a preventative effect for BPPV recurrences. However, there has not been a
randomized controlled trial conducted to confirm this effect to date. The goal of this study was to assess
whether the supplementation of vitamin D and calcium prevents recurrences of BPPV in participants with
vitamin D deficiency or insufficiency.
64
Benign paroxysmal positional vertigo (BPPV), the most common type of vertigo, is a condition
characterized by spinning sensations often initiated by a change in head position. Although
episodes can be successfully treated with canalith repositioning maneuvers, there is a high
recurrence rate. There is evidence[13] that a vitamin D deficiency and decreased calcium levels
may be risk factors for BPPV. This randomized controlled trial was designed to assess the efficacy
of vitamin D and calcium supplementation for preventing the recurrence of BPPV.
What was studied?

This was a registered, two-arm, single blinded (assessor), multi-center randomized control clinical trial
that was designed to explore the efficacy of vitamin D and calcium supplementation for preventing the
recurrence of BPPV. It should be noted that the trial was registered about three weeks after the first
participant was enrolled. The first participant was enrolled on December 19, 2013 and 17 participants
were enrolled before the formal registration of the trial on January 8, 2014 due to a delay in the
translation of the protocol. Also, according to the registered protocol, the study was not blinded.
However, the paper states that the study was single-blinded (i.e., the assessors were blinded).
The study was powered to detect a 20% decrease in BPPV frequency over the course of a year, and
recruited 957 participants in South Korea who were successfully treated for BPPV with canalith
repositioning maneuvers. The average age in both groups was just over 60 years old. People who had co-
occurring central nervous system disorders or were already supplementing with vitamin D or calcium
were excluded. The participants were randomized to an intervention group or an observation group.
The participants in the intervention group had their vitamin D, calcium, phosphorus, and parathyroid
hormone levels measured at the beginning of the study. Participants with vitamin D levels of less than 20
ng/mL (n=348) were given supplements containing 400 IU of vitamin D3 and 500 milligrams of calcium
carbonate twice a day. If a participant’s vitamin D levels were at least 20 ng/mL (n=152), they were not
given the supplement even though they were randomized to the intervention group. Participants in the
observation-only group did not have vitamin D levels measured and did not receive supplements. The
study followed participants for 12 months.
Several participants withdrew from the study, were lost to follow-up, or violated protocol, mostly from
the treatment arm, especially people who were assigned supplementation. While the observation arm
lost only 4% of participants over the course of the study, 38% of supplementing participants in the
intervention arm did not complete the study. Only 11% of participants who were randomized to the
intervention arm but had sufficient vitamin D levels, and so didn’t receive supplementation, didn’t
complete the study. The data were examined using intention-to-treat analysis, but only using
65
participants that completed at least one month of follow-up. This distinction was made due to the large
number of participants who dropped out of the intervention arm. There was also a per protocol group
analysis for participants who finished a one-year follow-up with more than 70% supplement compliance.
The original primary study outcome was the proportion of participants who had recurrences during the
one-year follow-up period. In May of 2016, more than two years after the study was registered, the
primary outcome was changed to an annual recurrence rate of BPPV (expressed as recurrences per one
person-year). The stated reason for the change in primary outcome was that participants could have had
several recurrences during the study period and the proportion of participants with recurrences would
not sufficiently reflect the major effect of the vitamin D and calcium supplementation. Secondary
outcomes were the proportion of participants with recurrences during the one-year follow up, changes in
serum 15-hydroxy vitamin D level, falling frequency, fracture frequency, and quality of life (evaluated
using the UCLA-dizziness questionnaire[14]).
Treatment efficacy was measured using incidence rate ratio (IRR) and reduction in the annual recurrence
rate (ARR). Subgroup analyses were performed to examine the influence of risk factors for BPPV
recurrences, including age, sex, BMI, type of BPPV, frequency of repositioning maneuver, previous
dizziness, previous ear disease, smoking, vascular risk, migraine, motion sickness, bone material density,
and independent walking.
This study was a single-blinded (assessor) randomized controlled trial that included participants
who were successfully treated for BPPV from eight hospitals in South Korea. The investigators
randomized about 1,000 participants into an intervention group in which participants with a
vitamin D level of less than 20 ng/mL received two daily doses of 400 IU of vitamin D3 and 500
milligrams of calcium carbonate for one year, or an observation-only group that just received
follow-up. The primary outcome was the annual recurrence rate of BPPV (expressed as
recurrences per one person-year). The secondary outcomes were the proportion of participants
with recurrences during the follow-up, changes in vitamin D level, annual fall rate, annual fracture
rate, and quality of life.

In the intervention group, there was a decrease in the annual recurrence rate of BPPV (0.83; 95% CI
0.74-0.92 vs. 1.10; 95% CI 1.00-1.19). In the per protocol group analysis (i.e., follow-up for one year), there
were similar effects (ARR=0.83 in the intervention group; ARR=1.12 in the observation group). When
vitamin D levels were deficient (no more than 10 ng/mL) or insufficient (between 10 and 20 ng/mL), the
effect of supplementation was even more pronounced. Participants who were most deficient in vitamin D
66
at the beginning of the study experienced the greatest benefit. Participants with vitamin D levels of less
than 10 ng/mL had a 45% reduction in ARR and participants with vitamin D levels between 10 and 20 ug/
mL had a 14% reduction in ARR. Thirty-eight percent of the participants in the intervention group had
another vertigo episode, while 47% of the participants in the observation group had another vertigo
episode. The ARR was indicative of a protective effect of supplementation in all of the clinical variables
except age of less than 65, no vascular risk factors, history of migraine, ear canals involved, type of BPPV,
and the ability to walk independently.
For secondary outcomes, the proportion of people with BPPV recurrences was 9% less in the intervention
group than in the observation group (37.8; CI 33.3-42.3 vs. 46.7; CI 42.4-51.0). Serum 25(OH) vitamin D
level increased by about 11 ng/mL (CI 10.0-11.9) after both 2 and 12 months of supplementation. The
frequency of falls seemed to increase in the intervention group. Fracture rate did not differ between the
groups. There were no values presented for the quality of life scores, but the authors reported that both
groups exhibited a significant improvement in the quality of life scores.
Selected primary and secondary outcomes are graphed along with their 95% confidence intervals in
Figure 2.
Figure 2: Select primary and secondary outcomes along with 95% confidence intervals
67
Three deaths were reported in the observation group. The authors state that the causes of death were
not related to the use of the study medication. However, this is a confusing statement because
medication was not used in the observation group. No other adverse effects were reported for the
observation group. No deaths were reported in the intervention group. However, 26 adverse events,
including anorexia, indigestion, constipation, edema, itching, hives, hypercalcemia, and loose stool were
reported.
The researchers calculated the number needed to treat to be 3.7 (95% confidence interval: 2.50-7.14).
This number refers to the number of people who need to take a drug in order for one person to
reasonably expect to experience a benefit.
68
Participants in the intervention group had a lower recurrence rate of BPPV following successful
treatment with head maneuvers than participants in the observation group. The proportion of
people with BPPV recurrences was also significantly less in the intervention group. Participants
with vitamin D levels of less than 10 ng/mL at the beginning of the study experienced the greatest
benefit.
The bigger picture

Ear organs are responsible for hearing and balance. Otoconia are present in the organs that are
responsible for balance. People feel dizzy when otoconia are dislodged and move into areas where they
do not belong. It makes sense that calcium and vitamin D (which interacts with calcium)
supplementation is relevant to otoconia correction in people with BPPV because otoconia are calcium
carbonate crystals. At face value, the results of the study suggest that supplementation with vitamin D
and calcium may help prevent the common recurrence of BPPV.
However, there are several issues with this study that warrant not taking these results at face value. First,
the intention-to-treat analysis was conducted on participants followed for at least one month, as
opposed to participants who were followed for one year, as presented in the original protocol. The stated
reason for this change is questionable. To draw an accurate, unbiased conclusion about the effectiveness
of the intervention and to preserve the benefits of randomization, all participants who were randomized
should have been included in the statistical analysis.
The second issue is that the trial was pitched as having a pragmatic design, which justifies the lack of
placebo and blinding of participants. Pragmatic trials are intentionally designed to assess the
effectiveness of interventions in real-life practice conditions. In this trial, however, the absence of
blinding and a placebo could introduce bias, especially since the main outcome was self-reported. It
seems possible that the observed effect could be partially or entirely due to placebo effect and/or social
desirability bias, where volunteers give responses they think the researchers want to hear. Furthermore,
the researchers did not measure the vitamin D levels of participants in the observation group, so it is
impossible to determine if vitamin D levels correlate with recurrence of BPPV.
The third issue is that the baseline vitamin D level was greater in participants included in the analysis of
the supplement effects, compared to the participants who were excluded. This potentially creates bias.
The researchers provided a link to examine their data in more detail. However, the NERD editors were
unable to locate this data. Further attempts to contact the lead author to obtain the data were
unsuccessful.
69
To the researchers’ credit, they performed an analysis (presented in Figure 3) that provides an in-depth
subgroup analysis showing that participants in the intervention with reduced vitamin D levels at the start
of the study who consequently received supplementation did experience a significant reduction in their
annual recurrence rate, an effect that was not apparent for participants who did not need
supplementation. However, almost 40% of participants assigned to receive vitamin D and calcium
withdrew from the study. This raises concerns about compliance with the supplementation protocol,
especially since the participants could have withdrawn due to some of the well-known adverse side
effects[15] of calcium carbonate, some of which were observed in the intervention arm at a much higher
rate than the observation arm.
Figure 3: Annual recurrence rate (with 95% confidence intervals) of BPPV by subgroup
In the U.S., between 2011 and 2014, the percentage of people at risk of vitamin D deficiency and
inadequacy[16] was 5% and 18%, respectively. Although there were flaws in the current study, it still
provides some evidence to suggest that people experiencing BPPV may benefit from being screened for
vitamin D deficiency and insufficiency, and that people who are deficient or insufficient (less than 20 ng/
mL) may benefit from supplementation.
70
However, given the study’s limitations, more research would be useful to confirm these findings. It may
also be helpful for future research to extend these findings, too, especially in people with BPPV whose
vitamin D levels are more than 20 ng/mL but less than 30 ng/mL (considered low/normal vitamin D
range), since people in this range did not supplement in this study. In addition, more work needs to be
done to determine the dose-response relationship between vitamin D levels and BPPV, estimate an
optimal level of vitamin D supplementation required to prevent recurrence of BPPV, and to determine if it
is necessary to include calcium in the supplementation protocol.
There were critical issues with this study, including a lack of a placebo and blinding and a large
dropout rate in the intervention group. Given the limitations of the study, this study should be
taken as weak, preliminary evidence that vitamin D and calcium can prevent recurrences of BPPV.
That said, since many people have low vitamin D levels and this study found that people with the
lowest starting levels benefited the most, people with BPPV should have their vitamin D levels
evaluated, and consider supplementation if their vitamin D levels are low.

Q. Is there evidence showing that a vitamin D deficiency is correlated with BPPV?
Yes. The association of serum vitamin D deficiency and BPPV has been documented in Korea[17], Austria
[11], Egypt[12], and China[18]. However, this illustrates correlation, not causation. There is not enough
evidence at this point in time to establish that vitamin D deficiency actually causes BPPV.
Q. Is it true that vitamin D supplements may promote arterial calcification?
The effect of vitamin D on arterial calcification has not been completely elucidated and remains
controversial. Studies have shown that an excess of vitamin D is associated with calcification. However,
other studies have shown that a deficiency of vitamin D promotes calcification. It could be that vitamin D
activity includes a biphasic response.
What should I know?

This study found that people with BPPV and vitamin D levels under 20 ng/mL supplementing 400 IU of
vitamin D3 and 500 milligrams of calcium carbonate twice a day for a year reduced their BPPV recurrence
risk. However, there were several issues with the study, which leave a lot of room for doubt when
evaluating these findings.
71
While future research should confirm these findings, this study provides preliminary evidence that it may
be useful for people with BPPV to have their vitamin D levels checked and consider vitamin D
supplementation if their levels are low.
Do you think the problems with this study are enough to cast doubt on the pretty big effect size
that the researchers found? Share your thoughts, and see what other nutrition nerds are saying,
over at our private Facebook forum.
 References
1. ^ Ji-Soo Kim, David S Zee. Clinical practice. Benign paroxysmal positional vertigo. N Engl
J Med. (2014)
2. ^ R W Baloh, V Honrubia, K Jacobson. Benign positional vertigo: clinical and oculographic
features in 240 cases. Neurology. (1987)
3. ^ Takao Imai, et al. Classification, diagnostic criteria and management of benign
paroxysmal positional vertigo. Auris Nasus Larynx. (2017)
4. ^ R A Nunez, S P Cass, J M Furman. Short- and long-term outcomes of canalith
repositioning for benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg.
(2000)
5. ^ M von Brevern, et al. Epidemiology of benign paroxysmal positional vertigo: a
population based study. J Neurol Neurosurg Psychiatry. (2007)
6. ^ Thomas Brandt, et al. Benign paroxysmal positioning vertigo: a long-term follow-up
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advantages and disadvantages. J Vestib Res. (2013)
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73
Credits
Researchers
Wyatt Brown; Dylan T. Dahlquist, MSc, CSCS; Antonis Damianou, MSc; Brad Dieter, PhD; Rachel Hathcock,
BSN, RN, CCRA; Nick Milazzo, MS(c); Katherine Pett, MS, RDN; Thomas Reichhart, MSc; Brandon Roberts
PhD, MS, CSCS; Lucas Roldos Saibene, BSc, MSc(c); Jill Ryer-Powder, PhD; Lucas Tafur, PhD
Editors
Gregory Lopez, MA, PharmD
Reviewers
Stephan Guyenet, PhD & Adel Moussa, PhD
Copy Editor
Dmitri Barvinok
Infographics
Antonius Khengdro & Calla Lee
74
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Issue #73 November 2020

Deep Dive: Does beta-alanine improve training performance?

Probiotics for celiac disease

Nerd Nulls: September-October 2020

Is honey an effective remedy for symptoms of upper respiratory tract infections?

Deep Dive: Reducing common vertigo with vitamin D and calcium

 Read this article online at Examine.com

Type 1 diabetes (T1D) is an autoimmune disease characterized by insufficient insulin production as a

^ Go back to table of contents

 Read this article online at Examine.com

How was it answered? Researchers conducted a randomized controlled crossover

What's the main takeaway? Trimethylamine-N-oxide (TMAO) levels were about

What was the question?

Why was the question worth asking?

How was the question answered?

What was the answer?

How much should you trust the answer?

How reliable is TMAO as a risk factor for CVD?

Are the findings of this study consistent?

What about the order effect?

Are there any other limitations?

What’s the take-home?

^ Go back to table of contents

 Study under review: Effects of Beta-Alanine Supplementation on Physical Performance in Aerobic-

 Read this article online at Examine.com

How was it answered? Researchers conducted a meta-analysis of randomized

Who was studied? Participants included healthy adults undergoing a variety of

What’s the main takeaway? Researchers observed small effects on most

What was studied?

What were the findings?

Figure 1: Effects of beta-alanine supplementation with 95% confidence intervals

The bigger picture

Frequently asked questions

Q. Is there any health benefit from BA supplementation?

^ Go back to table of contents

1. ^ Christopher W Sundberg, Robert H Fitts. Bioenergetic basis of skeletal muscle fatigue.

 Read this article online at Examine.com

What was the question?

Why was the question worth asking?

How was the question answered?

Figure 1: How the different effects were measured

Quality of life Celiac Disease Questionnaire Quality of Life Subscore

Irritable Bowel Syndrome Quality of Life Questionnaire.

Safety Adverse events

Inflammation Changes in serum levels of tumor necrosis factor-α

Intestinal Lactulose/mannitol ratio

Microbiome Changes in fecal microbiota

What was the answer?

Analysis Outcome Number of Quality Anything else of note?

GSRS Approximately Two, with a The analysis

All studies No Four, with a The analysis

How much should you trust the answer?

What’s the take-home?

^ Go back to table of contents

 Read this article online at Examine.com

Keep the following in mind when interpreting a null effect:

Cognition & memory

Diabetes & blood sugar

Infants, children & teenagers

Muscle gain & exercise

Outside the box

Pain, joints & bones