Presented by Kiran Krishnan Chief Science Officer, Microbiome Labs, LLC.

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1 Presented by Kiran Krishnan Chief Science Officer, Microbiome Labs, LLC.

2 Vitamin K Discovered in 1929 K stands for koagulation Fat-soluble vitamin (A, D, E and K) Activates vitamin K-dependent proteins (VKD) Current RDI is µg/day for blood clotting

3 Natural Sources of Vitamin K Vitamin K2 (Menaquinone) O H O n Vitamin K1 (Phylloqinone) O H O 3

4 Dietary Sources of Vitamin K2 - Natto Vitamin K2 as Menaquinone-7

5 Tissues in need for Vitamin K K1 clotting factors II, VII, IX, X, C, S, Z Vitamin K K2 Bone (Osteocalcin) K2 Arteries (Matrix Gla Proteins)

6 Function of Vitamin K2 Osteocalcin (OC) and Matrix Gla Protein (MGP) need vitamin K to become biologically active. Carboxylation K KH 2 KO CARBOXYLASE protein protein - Glu - Gla ucoc & ucmgp coc & cmgp KH 2 - vitamin K hydroxyquinone KO- vitamin K epoxide K- vitamin Glu - glutamic acid Gla - gammacarboxyglutamic acid Under-carboxylated Osteocalcin and MGP cannot function adequately in absorbing Calcium in the bones and inhibiting Calcium build up in the arteries respectively until carboxylated. Vitamin K2 is effective in the carboxylation of these VKD proteins.

7 Vitamin K2 and bone health Bone

8 Vitamin K2 and Osteocalcin Bone Osteocalcin is an vitamin K-dependent bone protein synthesized by Osteoblasts (bone building cells) Osteocalcin provides the bone matrix upon which calcium crystallizes Osteocalcin - provides the glue that holds calcium in the bone giving structure and order to bone tissue; without it bone would be fragile and easily broken Vitamin K2 activates osteocalcin through a process called carboxylation Without carboxylated osteocalcin, calcium cannot be properly utilized for bone structure

Vitamin K2 Intake and Fracture Rates Epidemiology Eastern

26 ± 6.13 ng/ml 1.22± 1.85 ng/ml 0.37 ± 0.

$high Vitamin K2 blood levels and decreased hip fracture rates.$

9 Vitamin K2 Intake and Fracture Rates Epidemiology Eastern Japanese Woman Western Japanese Woman British Woman MK ± 6.13 ng/ml 1.22± 1.85 ng/ml 0.37 ± 0.20 ng/ml Fracture Rate Conclusion: High Natto consumption means high Vitamin K2 blood levels and decreased hip fracture rates. Kaneki et al. Journal of Nutrition 2001 Vitamin K2 levels are inversely related to hip fracture rates.

10 Natural Vitamin K2 as MK-7 from Natto is Effective Bone 2001 Kaneki, et al high consumption of MK-7 levels from natto resulted in better levels of activated osteocalcin and a reduced risk fracture 2006 Ikeda, et al - natto consumption helps prevent the development of osteoporosis 2008 Yaegashi et al - showed that better vitamin K status attributed to Natto resulted in the reduction of hip fracture risk.

11 Osteocalcin carboxylation, BMD and fracture rate Bone Szulc et al: ucoc inversely correlates with BMD Knapen et al: ucoc inversely correlated with BMD Vegnaud et al: serum ucoc predicts hip fracture Luukinen et al: serum ucoc predicts hip fracture Szulc et al: high ucoc // 6-fold increased fracture risk

12 Vitamin K2 and vascular health CVD

Vitamin K2 and vascular health CVD First it was blood cholesterol that could give you an early warning that a heart attack might be around the corner. Then came C - reactive protein.

13 Vitamin K2 and vascular health CVD First it was blood cholesterol that could give you an early warning that a heart attack might be around the corner. Then came C - reactive protein. And now that doctors can get a better look at what's inside your heart and arteries, they are taking a new interest in something they have always known was present in problem vessels: calcium. Time Magazine 2005

14 Ashit Vora Synergia Life Sciences P Ltd. Vitamin K2 and vascular health CVD Predictors of outcome in severe, asymptomatic aortic stenosis Rosenhek, et al. New England Journal of Medicine 2000

15 MGP (Matrix Gla Protein) when activated is only known inhibitor of arterial calcification calcium MGP

16 CVD In red localization of inactive MGP Von Kossa staining. In black calcification Inactive MGP leads to calcification Schurgers et al, Arterial Thrombosis and Vascular Biology 2005

(means from 3 donors) CVD 250 200 Vitamin K1

17 Vitamin K (nmol/g tissue) K-vitamins in healthy and atherosclerotic human aorta s (means from 3 donors) CVD Vitamin K1 Vitamin K Healthy aorta Atherosclerotic aorta

18 Vitamin K2 and vascular health Rotterdam Study CVD Objective Design To study the association of dietary intake of K 1 and K 2 with aortic calcification, CVD, and total death cross-sectional analysis in healthy adults Setting 4807 men and women aged 55 and older; 10 years follow-up Measurements calcification end point (death) Geleijnse et al. Journal of Nutrition 2004

Risk for event (Hazard ratio) Conclusion Rotterdam CVD Study 120 100 80 60 40 20 0 <21 21-32 >32 Dietary vitamin K2 intake (µg/day) Aorta calcification Cardiovascular mortality All cause mortality

19 Risk for event (Hazard ratio) Conclusion Rotterdam CVD Study < >32 Dietary vitamin K2 intake (µg/day) Aorta calcification Cardiovascular mortality All cause mortality When consuming daily 45 µg dietary K2 you have: 50% reduction of arterial calcification 50% reduction of cardiovascular death 25 % reduction of all cause mortality as compared to low intake of dietary K2! There was no correlation for vitamin K1 in this study! Geleijnse et al. Journal of Nutrition 2004

Study Design Subjects Treatment Outcome Analysis of food intake using food frequency questionnaire 16057 women, aged 49-70 yrs free from CVD Vitamin K2 intake was 29.1 ± 12.

20 Study Design Subjects Treatment Outcome Analysis of food intake using food frequency questionnaire women, aged yrs free from CVD Vitamin K2 intake was 29.1 ± 12.8 mg/d With every 10 µg/day increment of Vitamin K2 intake, an inverse association between Vitamin K2 and risk of CHD was observed. A high intake of only Menaquinones, especially MK-7, MK-8 and MK-9, could protect against CHD. G.C.M. Gast : Nutrition, Metabolism & Cardiovascular Diseases (2008), 1-7

22 Ashit Vora Synergia Life Sciences P Ltd.

$On one hand, severe forms of cardiovascular diseases (heart failure, myocardial infarction, hypertension, severe AAC) are associated with higher risk of osteoporotic fracture, especially hip fracture.$

23 Osteoporosis & Cardiovascular Disease were once thought to be unrelated conditions. Men and women with cardiovascular diseases and peripheral arterial disease tend to have lower areal and volumetric bone mineral density (BMD) as well as faster bone loss, although findings vary according to skeletal site. On one hand, severe forms of cardiovascular diseases (heart failure, myocardial infarction, hypertension, severe AAC) are associated with higher risk of osteoporotic fracture, especially hip fracture. Studies indicate the common factor may be ineffective metabolism and utilization of Calcium. Szulc P. Association between cardiovascular diseases and osteoporosis reappraisal. BoneKEy reports. 2012;1:144. doi: /bonekey Patients affected with osteoporosis, for example, have a higher risk of cardiovascular diseases than subjects with normal bone mass. Sprini D, Rini GB, Di Stefano L, Cianferotti L, Napoli N. Correlation between osteoporosis and cardiovascular disease. Clinical Cases in Mineral and Bone Metabolism. 2014;11(2):

24 HYPERVITAMINOSIS D VITAMIN D TOXICITY

27 Stimulation Vitamin D Stimulation Osteoblasts Uncarboxylated Osteocalcin Vitamin K2-7 Uncarboxylated MGP Unable to put calcium on bone Catches calcium and puts on bone Carboxylated Osteocalcin & MGP Prevents arterial calcification Unable to Prevent Arterial Calcification British Medical Journal (BMJ 2005): Prevention of fractures with Calcium and Vitamin D is not enough.combining Vitamin K, Vitamin D and Calcium seems ideal..

28 Diabetes and Insulin Resistance

29 Diabetes affects 194 million of the world s population as estimated by 2003 WHO survey with 10% of death accounted. The number of deaths is expected to increase by more than 50% in the next 10 years. (Siegel & Narayan, 2008)

30 Vitamin K2 and Diabetes.we have demonstrated for the first time that vitamin K2 supplementation for 4 weeks increased insulin sensitivity in healthy young men, which seems to be related to increased coc rather than modulation of inflammation. Although our study could not provide the underlying mechanism, we speculate that coc or vitamin K could modulate adipokines or inflammatory pathways other than the IL-6 pathways. Alternatively, coc can directly regulate glucose disposal at skeletal muscle or adipose tissues.

Objective To investigate whether dietary phylloquinone and menaquinones intake are related to

Design Prospective Cohort study in 38,094 Dutch men & Women, aged 20-70 years Setting 918

3 years follow-up Conclusions With each 10 µg increment of menaquinone intake, a linear, inverse

31 Objective To investigate whether dietary phylloquinone and menaquinones intake are related to risk of type 2 diabetes. Design Prospective Cohort study in 38,094 Dutch men & Women, aged years Setting 918 incident cases of diabetes years follow-up Conclusions With each 10 µg increment of menaquinone intake, a linear, inverse association with risk of type 2 diabetes was observed. Improvement in blood lipid profile. This study shows that the intake of Menaquinones reduces the risk of type 2 diabetes and helps in relieving Insulin Resistance. Diabetes Care 33: , 2010

Objective To investigate the hypothesis that vitamin K supplementation for 36 months will improve insulin

Design An ancillary study of randomized, double-blind, controlled trial.

Conclusions Homeostasis model assessment of insulin resistance (HOMA-IR) & plasma insulin concentrations

32 Objective To investigate the hypothesis that vitamin K supplementation for 36 months will improve insulin resistance in older men and women. Design An ancillary study of randomized, double-blind, controlled trial. Setting 355 men & women aged years with supplementation of 500 µg/day Vitamin K for 36 months. Conclusions Homeostasis model assessment of insulin resistance (HOMA-IR) & plasma insulin concentrations were statistically significantly lower at the 36-month visit. Vitamin K supplementation for 36 months at doses attainable in the diet may reduce progression of insulin resistance. Diabetes Care 31: , 2008

34 Prognostic value of coronary artery calcium screening in subjects with and without diabetes low risk of death High risk of death Raggi, et al. J Amer Coll Cardio 2004

35 ADDITIONAL CLINICALLY PROVEN INDICATIONS Vitamin K2 shown to reduce diabetes risk by 20% in a Dutch population study over 10 years 38,000 patients Vitamin K2 shown to decrease cancer risk. Study on 23,000 German adults. Showed higher K2 intake associated with a lower likelihood of developing and dying of cancer. Vitamin K2 shown to reduce prostate cancer risk by 35% in a epic study in 11,319 men taking part in the Heidelberg cohort.

36 NEW DISCOVERIES IN VITAMIN K2 FUNCTION A SEEMINGLY OMNIPRESENT VITAMIN..

37 NEW MECHANISM OF K2 ACTION Redox Function of Vitamin K2 A significant role in the mitochondria Function in Nerve Health Function in Muscle Contraction Function in Cardiac Function and Output

38 YET ANOTHER MECHANISM 1950 s Redox cycle activity of vitamin K was proposed by Martius, et al s At a later date Johnson et al, refuted this claim. NADH NAD + ADP ATP

40 NADH NAD + ADP ATP Vitamin K-Mitochondrial Respiration

41 Mitochondrial Bioenergetics NADH NAD + ADP ATP Rotenone Antimycin FCCP X X Oligomycin Basal Respiration ATP Production Maximal Respiration H + X Proton Leak Non-mitochondrial Respiration Mitochondrial Respiration: Test sequence in sea horse XF-96 platform

42 OCR (PMOL/MIN) Vitamin K Bioenergetics Cellular Experiments Neuroblastoma cell line NADH NAD + ADP ATP OLIGOMYCIN FCCP AA/ROT K2-7 Natural (10 µm) Control MINS Mitochondrial Respiration: Test sequence in sea horse XF-96 platform

43 NADH ADP NAD + ATP

44 Science Jun 8;336(6086): doi: /science Epub 2012 May 10. Vitamin K2 is a mitochondrial electron carrier that rescues pink1 deficiency. Vos M 1, Esposito G, Edirisinghe JN, Vilain S, Haddad DM, Slabbaert JR, Van Meensel S, Schaap O, De Strooper B, Meganathan R, Morais VA, Verstreken P. Author information Abstract Human UBIAD1 localizes to mitochondria and converts vitamin K(1) to vitamin K(2). Vitamin K(2) is best known as a cofactor in blood coagulation, but in bacteria it is a membrane-bound electron carrier. Whether vitamin K(2) exerts a similar carrier function in eukaryotic cells is unknown. We identified Drosophila UBIAD1/Heix as a modifier of pink1, a gene mutated in Parkinson's disease that affects mitochondrial function. We found that vitamin K(2) was necessary and sufficient to transfer electrons in Drosophila mitochondria. Heix mutants showed severe mitochondrial defects that were rescued by vitamin K(2), and, similar to ubiquinone, vitamin K(2) transferred electrons in Drosophila mitochondria, resulting in more efficient adenosine triphosphate (ATP) production. Thus, mitochondrial dysfunction was rescued by vitamin K(2) that serves as a mitochondrial electron carrier, helping to maintain normal ATP production. Neuroscientist Patrik Verstreken, associated with VIB and KU Leuven, succeeded in undoing the effect of one of the genetic defects that leads to Parkinson's using vitamin K2. His discovery gives hope to Parkinson's patients.

45 Mitochondrial data gave us a clue that perhaps vitamin K2 could regenerate dysfunctional mitochondria in tissue a great example would be neurodegenerative diseases. N=30 Dosing: 100mcg/day Duration: 8 weeks Results: Well tolerated and significant alleviation of neuropathy

46 Severity of neuropathy Vit K2-7 reduces severity of neuropathy Results 8 7 Dose K2-7, 100mcg twice daily Weeks

Vitamin K2 and Vitamin K2 block 12-lypoxigenase (12-LOX) activation and inhibit accumulation of reactive oxygen species (ROS).

vitamin K prevents oxidative cell death indirectly by blocking activation of 12-LOX and ROS generation.

reduce inflammation and the consequences of autoimmune diseases RESULTS: MS subjects had 1/4 th the blood vitamin K2 levels

47 Vitamin K2 and Vitamin K2 block 12-lypoxigenase (12-LOX) activation and inhibit accumulation of reactive oxygen species (ROS). Vitamin K does not directly inhibit 12- LOX enzyme activity when evaluated with purified 12-LOX in vitro, suggesting that vitamin K prevents oxidative cell death indirectly by blocking activation of 12-LOX and ROS generation. The MK-4 or MK-7 can suppress IL6 and MK-4 can suppress prostaglandin E2 by inhibition of cox2; therefore, these compounds can reduce inflammation and the consequences of autoimmune diseases RESULTS: MS subjects had 1/4 th the blood vitamin K2 levels compared to age-matched healthy cohort. Female patients had significantly lower VK2 levels than males and a decrease with age by approximately 10% per decade was found.

48 NADH ADP NAD + ATP

49 Experimental Pharmacology Muscle Relaxant activity In vitro studies in smooth muscle and heart muscle A) Guinea Pig ileum Effect of MyoMax on smooth muscle contraction. Acetylcholine: Inhibition by 21.62%, 40%, 81.81% at 1,2,4, concentration.

50 Muscle Relaxant activity Barium Chloride: Vitamin K2 shows 30% inhibition Histamine: Vitamin K2 shows 33% inhibition of histamine induced contraction

51 Frog Heart Adrenalin: Vitamin K2 failed to inhibit adrenaline-induced contractions. Inference: Vitamin K2 did not show inhibition of the adrenalic (beta receptor agonist) response, which indicated that Vitamin K2 does not exhibit beta blocker activity. Thus suggesting that the peripheral perfusion effect is not due to a reduction in the arteriolar tone viz. decreasing peripheral resistance.

53 No. of cramps/day Month Group A No. of cramps/week Month Group B Study Results: Therapeutic Activity and Safety of Vitamin K 2-7 in Muscle Cramps Dose K2-7, 100mcg/day Dose K2-7, 0mcg Dose K2-7, 100mcg/day Dose K2-7, 0mcg

54 NADH ADP NAD + ATP

55 CARDIAC OUTPUT Stroke volume (SV) X Heart Rate (HR) During endurance racing or high intensity exercise, increased fractional use of VO2max and HRmax causes a decrease in speed and performance. The increased fractional use of HRmax and subsequent decrease I speed is counter intuitive and is likely associated with metabolic limitations of the mitochondria. Studies on Marathon runners have shown that over the course of the race, the athletes increase fractional use of HRmax from around 80% of HRmaxat the start to around 90% at the finish. This HR increase was associated with a continuous speed decrease. The upward drift in HR is one component of so-called cardiovascular drift, which is also characterized by a decrease in Stroke Volume (SV), overall Cardiac Output and in arterial and pulmonary pressures. Crandall and Gonzal ez-alonso, et al. have reported that a drop in SV (thus Cardiac Output) may be a major limiting factor in exhaustive exercise A common problem in individuals with a high-degree of aerobic training is that they tend to experience decreases in maximal heart rate, which is a side effect of training induced expansion of blood volume and possibly increased oxidative stress. Unfortunately, reduced maximal heart rate negatively influences the ability to maximize cardiac output and performance

57 Max Cardiac Output (L/min) Myomax-Base Myomax-Post Placebo-Base Placebo-Post CONCLUSION: Vitamin K2-7 supplementation was associated with a cardiovascular profile characterized by increased cardiac output, increased heart rate, and decreased blood lactate compared to placebo following 8-weeks of exercise training with the supplementation 12% increase of Cardiac Output Equivalent to 60 liter more blood in 1 hour of work 10 Without [vitamin K2-7] supplement, training induced changes in maximal cardiac output could take 6 months of continuous training to achieve. Supplementation with [vitamin K2-7] during training appeared to reduce this training window by ~60%.

58 ARGUABLY THE MOST IMPORTANT ANTIAGING NUTRIENT The Mitochondrial Free Radical Theory of Aging (MFRTA) proposes that mitochondrial free radicals, produced as by-products during normal metabolism, cause oxidative damage. According to MFRTA, the accumulation of this oxidative damage is the main driving force in the aging process. Especially Cardiac Mitochondrial Oxidant Production In a revealing study, a team of researchers showed that muscle tissue of a 90- year-old man contained 95% damaged mitochondria compared to almost no damage in that of a 5-year-old. By Kirk Stokel Linnane AW, Kovalenko S, Gingold EB. The universality of bioenergetic disease: age-associated cellular bioenergetic degradation and amelioration therapy. Ann N Y Acad Sci Nov 20;854:

59 ARGUABLY THE MOST IMPORTANT ANTIAGING NUTRIENT Studies indicated a decrease of cardiac output with aging at rest and with exercise. Melvin D. Cheitlin, MD. Am J Geriatr Cardiol. 2003;12(1) A substantially reduced output was a consistent finding in older subjects. MARTIN BRANDFONBRENER, M.D., MILTON LAN DOW-NE, M.D. AND NATHAN W. SHOCK, PH.D. CIRCULATION. October 1, 1955

BONE HEALTH/OSTEOCALCIN: OSTEOPOROSIS, DIABETES ARTERIAL CALCIFICATION: CARDIOVASCULAR DISEASE BONE STRENGTH AND FORMATION: ORAL HEALTH INHIBITION OF SOFT TISSUE CALCIFICATION: ELASTIN AND COLLAGEN

60 BONE HEALTH/OSTEOCALCIN: OSTEOPOROSIS, DIABETES ARTERIAL CALCIFICATION: CARDIOVASCULAR DISEASE BONE STRENGTH AND FORMATION: ORAL HEALTH INHIBITION OF SOFT TISSUE CALCIFICATION: ELASTIN AND COLLAGEN CONCLUSION NEURONAL MITOCHONDRIA RESCUE: NEURODEGENERATIVE DISORDERS SUCH AS PARKINSON S. MS, NEUROPATHY MUSCLE MITOCHONDRIA FUNCTION: CVD, CRAMPS, CARDIAC OUTPUT (AGING AND PERFORMANCE) IL6- AND ROS INHIBITION: AUTOIMMUNE CONDITIONS, AGE- RELATED DECLINE, CANCERS, DIABETES

What s New With Vitamin K2: New Discoveries on a Critical Nutrient Susan Allen RDN, CCN Hosts Kiran Krishnan!

What s New With Vitamin K2: New Discoveries on a Critical Nutrient Susan Allen RDN, CCN Hosts Kiran Krishnan! 2017 COPYRIGHT. ALL RIGHTS RESERVED Vitamin K2-7 Defining the structural integrity and rate