We previously published the case of a woman taking warfarin who was found to have scurvy, a disease caused by a deficiency of vitamin C. This led us to hypothesize that patients taking warfarin who consume a diet limited in vitamin K rich foods may be at risk for other nutrient deficiencies. To test our hypothesis, we studied dietary nutrient intake in patients taking warfarin compared to patients with heart disease not taking warfarin.
The warfarin (n=59) and control groups (n=24) comprised convenience samples of patients with heart disease over age 60 years. Patients completed a three-day food diary and reported use of supplements.
Based on diet history, the most common deficiencies were vitamin D (100% both groups), vitamin E (93% warfarin, 92% control), vitamin A (71% warfarin, 71% control), vitamin K (66% warfarin, 58% control), vitamin C (58 % warfarin, 46% control) and pantothenic acid (69% warfarin, 71% control) with no significant differences in intake deficiencies between warfarin and control groups.
All of our patients had nutritional intake deficiencies. This may be due to Appalachian dietary habits and not the low vitamin K diet. It seems prudent to recommend multivitamins, however, universal multivitamin supplementation has not been supported by randomized controlled trials. More study is needed to determine the reason for poor nutritional intake in our Appalachian population and to determine whether similar results are evident in a larger sample.
Conflict(s) of Interest
Authors have no conflict of interest and no financial disclosures
References with DOI
1. Yousef GM, Goebel LJ. Vitamin C deficiency in an anticoagulated patient. J Gen Intern Med. 2013 Jun;28(6):852-4. https://doi.org/10.1007/s11606-012-2282-3
2. Lowry R. Vassarstats statistical computation website. [Internet] [Cited August 1, 2014]. Available from: http://www.vassarstats.net.
3. Sesso HD, Christen WG, Bubes V, Smith JP, MacFadyen J, Manson JE, Glynn RJ, Buring JE, Gaziano JM. Multivitamins in the prevention of cardiovascular disease in men: the Physicians' Health Study II randomized controlled trial. JAMA. 2012 Nov 7;308(17):1751-60. https://doi.org/10.1001/jama.2012.14805
4. Bjelakovic G, Nikolova D, Gluud LL, Simonetti RG, Gluud C. Antioxidant supplements for prevention of mortality in healthy participants and patients with various diseases. Cochrane Database Syst Rev. 2012;3:Cd007176. https://doi.org/10.1002/14651858.cd007176.pub2
5. Moyer VA. Vitamin, mineral, and multivitamin supplements for the primary prevention of cardiovascular disease and cancer: U.S. Preventive services Task Force recommendation statement. Ann Intern Med. 2014 Apr 15;160(8):558-64. https://doi.org/10.7326/m14-0198
6. Massa J, Cho E, Orav EJ, Willett WC, Wu K, Giovannucci EL. Long-term use of multivitamins and risk of colorectal adenoma in women. Br J Cancer. 2014 Jan 7;110(1):249-55. https://doi.org/10.1038/bjc.2013.664
7. Grima NA, Pase MP, Macpherson H, Pipingas A. The effects of multivitamins on cognitive performance: a systematic review and meta-analysis. J Alzheimers Dis. 2012;29(3):561-9.
8. Flasher WC. Cultural diversity: eating in America Appalachian. OSUE [Internet], Ohio Department of Health, Ohio State University. 2010. [Cited June 25, 2014]. Available from: http:// www.ohioline.sou.edu/hyg- fact/5000/pdf/5252.pdf.
9. Crooks DL. Food consumption, activity, and overweight among elementary school children in an Appalachian Kentucky community. Am J Phys Anthropol. 2000 Jun;112(2):159-70. https://doi.org/10.1002/(sici)1096-8644(2000)112:2<159::aid-ajpa3>3.0.co;2-g
10. Centers for Disease Control and Prevention. Surveillance Summaries. MMWR. 2006 Jun 9;55(SS-5).
11. Centers for Disease Control and Prevention. The obesity epidemic and West Virginia students [Internet]. 2013. [Cited June 25, 2014]. Available from: http://www.cbc.gov/healthyyouth/yrbs/pdf/obesity/wv_obesity_combo.pdf.
12. Jilcott Pitts SB, Gustafson A, Wu Q, Leah Mayo M, Ward RK, McGuirt JT, Rafferty AP, Lancaster MF, Evenson KR, Keyserling Tc, Ammerman AS. Farmers’ market use is associated with fruit and vegetable consumption in diverse southern rural communities. Nutr J. 2014 Jan 9;13:1. https://doi.org/10.1186/1475-2891-13-1
13. Brown JL, Wenrich TR. Intra-family role expectations and reluctance to change identified as key barriers to expanding vegetable consumption patterns during interactive family-based program for Appalachian low- income food preparers. J Acad Nutr Diet. 2012;112(8):1188-200. https://doi.org/10.1016/j.jand.2012.05.003
14. National Institutes of Health Office of Dietary Supplements. [Internet]. [Cited June 25, 2014]. Available from: http://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/
15. Constantini NW, Arieli R, Chodick G, Dubnov-Raz G. High prevalence of vitamin D insufficiency in athletes and dancers. Clin J Sport Med. 2010 Sep;20(5):368-71. https://doi.org/10.1097/jsm.0b013e3181f207f2
16. Russell RM. Vitamin and trace mineral deficiency and excess. In: Braunwald E, Fauci A, Kasper D, Hauser SL, Longo DL, Jameson JL, editors. Harrison's Principles of Internal Medicine. vol 1. 15th ed. New York, NY: McGraw-Hill; 2001:465-6.
17. Institute of Medicine (US) Standing Committee on the Scientific Evaluation of Dietary Reference Intakes and its Panel on Folate, Other B Vitamins, and Choline. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. Washington DC: National Academy Press (US);[Internet]1998. 10, Pantothenic Acid. [Cited August 12, 2014] Available from: http://www.ncbi.nlm.nih.gov/books/NBK114311/
18. U.S. Department of Agriculture ARS. A National Nutrient Database for Standard Reference, Release 25. [Internet]. 2013. [Cited August 12, 2014] Available from: http://ndb.nal.usda.gov/ndb/nutrients/report/nutrientsfrm?max=25&offset=0&totCount=0&nutrient1=410& nutrient2=&nutrient3=&subset=0&fg=&sort=c&measureby=m.
19. Lumia M, Takkinen HM, Luukkainen P, Kaila M, Lehtinen-Jacks S, Nwaru BI, Tuokkola J, Niemela O, Haapala AM, Ilonen J, Simell O, Knip M, Veijola R, Virtanen SM . Food consumption and risk of childhood asthma. Pediatr Allergy Immunol [Internet]. 2015 Feb 18 [Cited February 18, 2015] Available from: http://onlinelibrary.wiley.com/doi/10.1111/pai.12352/abstract;jsessionid=42420320352FC65776A15 3B449363 67B.f01t04
20. Cheng G, Hilbig A, Drossard C, Alexy U, Kersting M. Relative validity of a 3 d estimated food record in German toddlers. Public Health Nutr. 2013 Apr;16(4):645-52. https://doi.org/10.1017/s1368980012003230
21. Buendia JR, Bradlee ML, Singer MR, Moore LL. Diets higher in protein predict lower high blood pressure risk in Framingham offspring study adults. Am J Hypertens. 2015 Mar;28(3):372-9. https://doi.org/10.1093/ajh/hpu157
22. Stram DO, Longnecker MP, Shames L, Kolonel LN, Wilkens LR, Pike MC, Henderson BE. Cost-efficient design of a diet validation study. Am J Epidemiol. 1995 Aug 1;142(3):353-62.
Riley, Philip IV; Lucas Day,, Kim MD; Yousef,, George M. MD; Devabhaktuni,, Sirisha MD; Gaing, Ashley N.; and Goebel,, Lynne J. MD
"A Case Control Study of Nutrient Intake Deficiencies in Patients Taking Warfarin,"
Marshall Journal of Medicine:
1, Article 2.
Available at: https://mds.marshall.edu/mjm/vol1/iss1/2