, 2025-04-17 18:22:00
CHICAGO — Physicians hear it daily: Internet search results prompting questions. Patients walk in primed with information they’ve gleaned from “Dr Google” and they’re looking for the official answer.
Three experts summarized their answers to the top questions that patients have after their scrolling sessions.
Erin D. Michos, MD, MHS, cardiologist and professor at the Johns Hopkins School of Medicine in Baltimore, said here at the American College of Cardiology Scientific Session 2025 that she gets a lot of questions about dietary supplements.
“Should I Take Calcium or Other Supplements?”
Thebottom line: “Stop wasting money,” Michos said. “Half of US adults take a supplement,” but “there is no evidence that taking a daily multivitamin helps cardiovascular outcomes.”
In a meta-analysis of 18 studies that she coauthored, which included more than 2 million patients taking multivitamin or mineral supplements, “it was essentially a wash,” she reported. “We didn’t see harm, we didn’t see benefit.”
As for calcium, several studies have suggested that calcium supplements might actually increase the risk for cardiovascular disease, she said.
In postmenopausal women, calcium supplements were associated with a 15% increase in the risk for cardiovascular disease and a 16% increase in coronary disease, according to a meta-analysis of 13 randomized controlled trials.
And a combination of calcium plus vitamin D supplements “didn’t show a reduction in fractures, cardiovascular disease, or cancer” in a study that was part of the Women’s Health Initiative. “Almost every outcome was null, except there was a 17% increased risk of kidney stones with calcium plus vitamin D supplements,” Michos said.
The largest vitamin D trial was the VITAL trial, in which more than 25,000 people got a high dose of vitamin D — 2000 IUs a day — or placebo. The hazard ratio for cardiovascular outcomes and cancer was null.
She suggested pointing patients instead toward moderate sun exposure and foods high in vitamin D, such as salmon, and foods high in calcium, such as leafy green vegetables, beans, and figs.
“You do need to have adequate dietary calcium of around 1000 mg a day, and for women over 50, 1200 mg a day,” Michos said. “Try to get as much as you can from food. If you need to take a supplement, take the smallest amount — 500 mg or less —because of the concern of harm.”
Dariush Mozaffarian, MD, DrPH, cardiologist and director of the Food is Medicine Institute at Tufts University in Boston, said he hears a lot of questions about new diets.
How Will the Diet I’m Trying Affect My Health?
“For too long, we’ve demonized and vilified food: too much fat, too much sugar, too much salt,” said Mozaffarian. “Really, the fundamental problem of why we have so much disease is that we’re not eating enough of the good foods,” he said. Rather than telling patients to eliminate things from their diet, encourage eating more of the good, protective foods, he said.
Think of food in three buckets, he pointed out: protective foods, foods to eat in moderation, and foods to avoid. Mozaffarian said he helps patients set goals to eat more of the protective foods, which include fruits, nuts, fish, vegetables, plant oils, whole grains, beans, and yogurt.
These foods are minimally processed, rich in fiber, and have nutrients that nurture the microbiome, he said.
“Starch is the single biggest problem in the US food supply,” he said, pointing to ingredients such as refined flour and rice. The worst things in the food supply are the ultra-processed foods high in starch, sugar, and salt. It’s not fat, sugar, and salt; it’s starch, sugar, and salt,” he said.
“Obesity has gone up in the United States over the last 20 years with no change in calorie intake, and physical activity has gone up. Why? It’s because of ultra-processed foods,” Mozaffarian said.
There’s hope that a shift in healthcare spending will encourage eating more protective foods. “We’re starting to be able to use healthcare dollars and prescriptions to start prescribing protective foods for patients, particularly those who are low income and have insurance pay for these healthy foods,” he said.
Steven Nissen, MD, chair of cardiovascular medicine at the Cleveland Clinic, said he is also concerned about rising rates of testosterone use outside of medical care.
I Need My Testosterone. What Will it Do to My Heart?
“Testosterone use in men is out of control,” Nissen said. He pointed to the proliferation of “low T” centers that are contributing to the frenzy.
In 2014, the FDA convened an advisory panel to study the potential connection between testosterone and cardiovascular events after increased reports of stroke and heart attack.
Some of the information from that panel was “very disturbing,” Nissen said. “About 20% of the men taking testosterone — hundreds of thousands — have never had a blood level of testosterone obtained by their physicians.”
After reviewing the literature, the FDA “called out the use of testosterone to treat normal aging, which is inappropriate,” Nissen said.
The FDA put out a safety communication about the possible increase in cardiovascular risk, required labeling changes, and, most important, it “required manufacturers of approved products — 11 manufacturers — to conduct a well-designed clinical outcome trial to address the question, and they came to us to do the trial,” Nissen reported.
That trial, TRAVERSE, randomized people to testosterone gel or placebo. The primary result is “that we did not see excess cardiovascular events with the use of testosterone in a carefully titrated environment,” Nissen said.
“However, we did see some adverse events,” he said. They included “nonfatal arrhythmias, mostly atrial fibrillation, and a marginally significant incidence of increased acute kidney injury.”
But a secondary analysis “was very surprising,” Nissen reported. “We expected bone health would be improved by testosterone. That’s what the literature had said in multiple studies, but in fact there was a 43% increased risk of fractures in people taking testosterone. And there were studies done that injectable testosterone, in particular, increased blood pressure by about 3.5 mm Hg. You may think that’s small, but I can tell you that even 2 mm Hg over a large population will increase the risk of stroke and probably myocardial infarction.”
In February, after reviewing the TRAVERSE findings, the FDA mandated labeling changes that removed the boxed warning on cardiovascular outcomes risk, but added a new warning about increased blood pressure.
The bottom line? “Yes, it’s okay to prescribe testosterone, but if two morning levels are less than 300 ng/dL, if the patient has symptoms of hypogonadism, levels of response therapy must be monitored and should be stopped if their hematocrit is above 54%.”
Michos reports no relevant financial disclosures. Mozaffarian reports receiving grants from the Gates Foundation, the Rockefeller Foundation, Kaiser Permanente Fund, About Fresh, the American Diabetes Association, the American Heart Foundation, Kroger, and family foundations; ties to Google and several pharmaceutical companies and health systems; and owning stock in Calibrate and HumanCo. Nissen has led multiple trials for multiple pharmaceutical companies but he directs all companies to pay any fees directly to charity.