Skip to main content

Cholecalciferol supplementation lowers leptin and TMAO but increases NO and VEGF-A levels in obese vitamin D deficient patients: Is it one of the potential cardioprotective mechanisms of vitamin D?



Vitamin D deficiency is one of the most common health issues in developed countries. Obese patients are most at risk of having serum 25-hydroxyvitamin D3 (25(OH)D3) levels that are too low due to the accumulation of vitamin D in adipose tissue. While the effects of a deficiency on the skeletal or immune system are known, the effects on the cardiovascular system are not yet clear. Our study investigates the effect of cholecalciferol supplementation in obese patients on selected biomarkers associated with cardiovascular diseases (CVDs).


The study enrolled 33 obese patients with insufficient 25(OH)D3 levels. For three months, the subjects supplemented with cholecalciferol at a dose of 2000 IU/day. Concentrations of nitric oxide (NO), vascular endothelial growth factor A (VEGF-A), leptin, trimethylamine N-oxide (TMAO) and soluble suppression of tumorigenicity 2 (sST2) were measured in baseline samples using ELISA (BioTek EPOCH). 25(OH)D3 levels measured on Beckman Coulter DXI 800 by chemiluminescence method.


After supplementation, 25(OH)D3 levels increased significantly. Normal levels were achieved in most patients. A statistically significant reduction leptin and TMAO levels was observed. At the same time, NO and VEGF-A levels increased statistically significantly.


This study indicates that restoring normal 25(OH)D3 levels in obese people reduces the concentration of pro-inflammatory factors associated with cardiovascular diseases. Reducing inflammation and the potential impact on vascular reactivity leads to the conclusion that cholecalciferol supplementation in obese patients may benefit the cardiovascular system.


The vitamin D receptor (VDR) is located in endothelial cells, vascular smooth muscle and cardiomyocytes [1]. Many studies have described the importance of vitamin D deficiency in the development of atherosclerosis, coronary heart disease, hypertension, heart failure and atrial fibrillation. Moreover, the cardioprotective role of this vitamin in patients after myocardial infarction has been described [2].

There is evidence that vitamin D can modulate the pathogenesis of atherosclerosis. An undoubted role in the development of atherosclerotic plaque is played by a chronic inflammatory process. Inflammation together with oxidative stress promotes impaired vascular perfusion, resulting in an increased risk of coronary artery disease [3]. Tare et al. observed that mesenteric arteries of 25(OH)D3 deficient rats were characterised by a twofold decrease in their ability to diastole. The pathomechanism of this process is related to impaired NO signalling and endothelium-derived hyperpolarizing factor (EDHF) [4, 5]. In the Framingham Offspring Study, which included 1739 subjects without heart disease, the risk of a cardiovascular incident was 53% to 80% higher in subjects with low 25(OH)D3 levels during a seven-year prospective observation [6]. Anderson et al. reported that American patients with vitamin D deficiency, defined as serum 25(OH)D3 levels < 30 ng/ml, reached 60% and significantly correlated with the occurrence of type 2 diabetes, hypertension, coronary heart disease (CHD), myocardial infarction (MI), heart failure (HF) and was associated with higher overall mortality [7].

Vitamin D deficiency likely leads to the development of cardiovascular diseases (CVDs) by an overactive renin–angiotensin–aldosterone system (RAAS). It has also been proven that low serum 25(OH)D3 concentration is associated with endothelial dysfunction and increases inflammation [8].

Many studies have shown that obese people have lower levels of 25(OH)D3 the serum compared to people of normal weight. A potential explanation for this phenomenon is vitamin D sequestration in adipose tissue [9]. Another hypothesis is that decreased 25(OH)D3 levels in obese people are due to a sedentary lifestyle and lack of physical activity. It is associated with lower exposure to sunlight and reduced skin synthesis [10]. Targher et al. suggest that lower 25(OH)D3 levels may be associated with impaired 25-hydroxylation in non-alcoholic fatty liver disease (NAFLD), which is common in obese patients [11].

We can distinguish two types of adipose tissue—white adipose tissue (WAT) and brown adipose tissue (BAT) [12]. Vascular endothelial growth factor A (VEGF-A) is indicated as an important protein in the development of BAT, which shows increased metabolism in contrast to WAT [13]. WAT performs an auto, para- and endocrine function, and the substances it secretes, called adipokines, are pro-inflammatory and anti-inflammatory. The pro-inflammatory adipokines include leptin, tumor necrosis factor (TNF-α), resistin, interleukin 6 (IL-6) and visfatin [14]. Obesity is associated with chronic inflammation that results from excess body fat [15, 16]. Recent clinical studies show a positive correlation between increased serum levels of trimethylamine N-oxide (TMAO) and an increased risk of adverse cardiovascular events. There is compelling evidence suggesting a relationship between TMAO and inflammation [17]. Studies have suggested that not only low vitamin D level but also high level of TMAO, which is associated with changes in the gut microbiota of obese individuals, are associated with the severity of NAFLD [18].

Nitric oxide (NO) plays an important role in regulating blood flow and pressure [19]. It is produced not only in the endothelium, but also in cardiomyocytes, smooth muscle cells, monocytes and macrophages, and in thrombocytes. It has an anticoagulant and antiplatelet effect by inhibiting the formation of the active GPIIb/IIIa receptor conformation, and affects the contractility of cardiomyocytes [20].

Leptin is a protein hormone belonging to the group of adipokines, produced by adipocytes. This peptide has been shown to activate the renin–angiotensin–aldosterone axis (RAA), increase the reabsorption of sodium in the renal tubules and stimulate the activity of the sympathetic nervous system [21].

The relationship between VEGF-A and the heart is two-sided. On the one hand, VEGF-A activates cardiomyocytes, inducing morphogenesis, contractility and wound healing. The concentration of VEGF-A increases in cardiomyocytes during inflammation and mechanical damage to the heart. Moreover, high concentrations of VEGF-A have been found in patients suffering from various CVDs, which are often correlated with poor prognosis and disease severity [22].

A new biomarker of heart failure is the ST2 (suppression of tumorigenicity 2) receptor, which belongs to the interleukin 1 (IL-1) receptor family. Of the 4 known isoforms of this glycoprotein, 2 play a special role in the physiology and pathophysiology of the cardiovascular system: transmembrane (ST2L) and soluble (sST2), present in the blood [23]. A meta-analysis by Ip et al. showed that sST2 significantly predicts severity and mortality in cardiovascular diseases and is a good predictor of mortality in patients with stable coronary disease and chronic heart failure [24].

The results of studies available in the literature on the discussed biomarkers remain inconclusive. We decided to investigate the effect of cholecalciferol supplementation in obese patients on the concentration of biomarkers with their potential role in CVD.

Material and methods

The study population consisted of selected patients of Primary Care Clinic in Poland. Inclusion criteria for the study were: age (subjects over 18 years old) and obesity (according to BMI). Exclusion criteria for participation in the study were: nicotinism, hormone replacement therapy, history of myocardial infarction or stroke within the past year, cancer, dialysis, liver disease, osteoporosis, pregnancy, vitamin D malabsorption (cystic fibrosis, Crohn's disease), allergy to components contained in the tablet of the drug, refusal to draw blood for the study. All subjects were in good health and were not on any special diet. The study was conducted between October 2019 and March 2020, eliminating the effect of UV-B radiation on dermal cholecalciferol synthesis. The study design was approved by the ethics committee of Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, in Toruń (approval number KB48/2019). The study was conducted according to the criteria set by the declaration of Helsinki and each subject signed an informed consent before participating in the study.

42 patients were included in the study and consented to participate in it. Nine dropped out during the study or did not show up for repeat blood draws. 33 patients (17 males and 16 females aged, 23–71) completed the study. Table 1 shows basic anthropometric data of the subjects.

Table 1 Anthropometric data of patients

Patients were screened for serum vitamin D level, determined as 25(OH)D3, and for markers such as NO, VEGF-A, leptin, TMAO and sST2. The criterion for serum 25(OH)D3 deficiency was a serum concentration < 30 ng/ml. Subsequently, patients received cholecalciferol at a dose of 1000 IU (25 µg) per tablet. 180 tablets were the amount needed for 90 days of treatment. They were advised to take two tablets once daily after a meal in the morning for 3 months. After this time, serum 25(OH)D3 and marker levels were controlled again (Table 2).

Table 2 Statistical data before and after supplementation

Body mass index (BMI) was calculated as weight in kilograms divided by height in meters squared. The concentration of 25(OH)D3 at all stages of the experiment was measured on a Beckman Coulter DXI 800 by the chemiluminescence method (mini Vidas Blue 25 H Vitamin D total quantitative kit). Biomarkers were determined with the ELISA method on a BioTek EPOCH Instrument using Elisa Kits by SunRed for factors as NO, leptin, TMAO, sST2, VEGF-2.

Statistical analysis

Data analysis were performed with Statistica 13.3. All results were presented as mean values with standard error of the mean (± SEM). Statistical significance was determined with the dependent t-test. The compliance of the results distribution with the normal distribution was checked using the Shapiro–Wilk test separately for the results obtained before (Time point 1) and after the 3-months cholecalciferol supplementation (Time point 2).Values of p ≤ 0.05 were considered statistically significant.


After 3 months of supplementation with cholecalciferol 2000 IU/day in obese people, a decrease in the level of leptin and TMAO as well as an increase in the level of NO and VEGF-A was observed. There were no statistically significant changes in serum sST2 concentration. The box plots (Fig. 1) show the concentrations of individual markers and 25(OH)D3 before therapy (Sample 1) and after 3 months of supplementation (Sample 2). Leptin concentration decreased from 16.90 ± 1.65 ng/ml to 14.72 ± 1.78 ng/ml and TMAO concentration from 63.41 ± 12.59 ng/ml to 59.98 ± 12.36 ng/ml. A significant increase in VEGF-A (298.81 ± 27.44 vs. 322.91 ± 26.02 pg/ml), NO (39.19 ± 10.96 vs. 70.02 ± 13.80 µmol/l) and 25(OH)D serum levels (18.22 ± 1.10 vs. 29.89 ± 1.16 ng/ml) was observed (Fig. 2).

Fig. 1
figure 1

Concentration of markers and 25(OH)D3 before (1) and after 3 months of cholecalciferol supplementation (2). A leptin, p = 0.029; B TMAO, p = 0.022; C NO, p = 0.021; D VEGF-A, p = 0.024; E sST2, p = 0.065; F 25(OH)D3, p < 0.001

Fig. 2
figure 2

Suggested mechanism for the effect of vitamin D on adipose tissue

Table 3 shows the gender distribution of 25(OH)D3 levels before and after supplementation. Before the supplementation, none of the patients was in the group with the optimal 25(OH)D3. After 3 months of treatment, the 25(OH)D3 level increased significantly in all the subjects, and none of the patients was in the severely deficient group. Most of the patients achieved suboptimal or optimal 25(OH)D3 levels (men 47.06% and 47.06%, women 50.00% and 43.75%).

Table 3 Distribution of 25(OH)D3 levels before and after supplementation according to gender (%)

According to WHO recommendations, 13 patients were classified as obesity grade I, 12 patients as obesity grade II, 7 patients as obesity grade III, and one patient as overweight (Table 4).

Table 4 Obesity classification


Almost 10 years ago, Gotsman et al. published a study in which they showed that vitamin D deficiency is associated with a higher risk of death in patients with heart failure (HF) [25]. Patients who develop HF show lower serum 25(OH)D3 levels [25]. Researchers also observed a greater risk of subsequent HF in patients with vitamin D deficiency suffering from hypertension [26]. In the meta-analysis by Bjelakovic et al. on two-year cholecalciferol supplementation, lower mortality is observed among people with vitamin D supplementation compared to the control group [27]. A study conducted on over two million Americans indicates that a higher daily intake of cholcelciferol correlates positively with a lower risk of CVDs in men, while in women this relationship was statistically insignificant [28]. These studies may indicate an important role of vitamin D in the proper functioning of the circulatory system. Our study evaluates the effect of cholecalciferol supplementation on serum biomarkers associated with CVDs (NO, leptin, TMAO, VEGF-A, sST2) in obese patients with 25(OH)D3 deficiency.

We found that leptin and TMAO levels decreased after 3 months of cholecalciferol supplementation, while levels of NO and VEGF-A increased. There were no statistically significant changes in the serum concentration of sST2. It has been shown that both the observed decrease in the level of pro-inflammatory proteins and the increase in the level of VEGF-A positively correlate with a lower risk of CVD. In contrast, higher levels of sST2 indicate a higher risk of CVD. The role of NO in the peripheral regulation of the circulatory system is mainly related to the vasodilatory effect. The increase in NO synthesis leads to vasodilation, which results in an increase in blood flow and a decrease in peripheral resistance in the circulatory system. The synthesis of NO in the vessels is mainly related to the activity of endothelial nitric oxide synthase (eNOS), which is regulated depending on various factors, including serum 25(OH)D3 concentration [29, 30]. Al-Daghri et al. indicated a negative correlation between the concentration of NO and 25(OH)D3 in the serum of healthy adolescents [31]. On the other hand, Huang et al. proved that calcitriol improves the functioning of endothelial cells by increasing NO in patients with systemic lupus erythematosus [32]. According to the research of Andrukhova et al., vitamin D improves the functioning of the endothelium by increasing the transcription of genes encoding eNOS [33]. Studies in mice have shown that animals lacking eNOS or the neuronal nitric oxide synthase (nNOS) gene increase the risk of metabolic syndrome and possible vascular consequences [34]. Therefore, it seems that NO, apart from its vasodilatory effect, may play an important role in the pathogenesis of obesity.

In our study, the concentration of NO in patients was 39.19 ± 10.96 µmol/L before cholecalciferol supplementation and increased to 70.02 ± 13.80 µmol/L after three months of supplementation (p = 0.021). The obtained results are consistent with the data published by Huang et al., who showed that vitamin D increases the expression of eNOS and increases the bioavailability of NO [32]. Wolf et al. in their study assessed the relationship between serum 25(OH)D3 concentration and the susceptibility of skin vessels to dilation under the influence of temperature. They observed that after four weeks of oral vitamin D supplementation in a dose of 2000 IU, a significant increase in the mean concentration of 25(OH)D3 in the serum of the subjects was achieved (from 17.93 ± 5.24 to 26.07 ± 3.73 ng/mL, p = 0.04). Cholecalciferol supplementation for 4 weeks increased NO concentration and vasodilatation [35]. On the other hand, the meta-analysis by Akbari et al. showed that cholecalciferol supplementation caused a significant decrease in high-sensitivity C-reactive protein (hs-CRP), but did not affect NO levels [36].

High level of leptin, positively correlates with risk of CV events like coronary heart disease (CHD) [37], stroke [38, 39] or coronary events [40]. Clinical trials have shown that elevated serum leptin levels are associated with the risk of hypertension [41]. This peptide has been shown to activate the renin–angiotensin–aldosterone system (RAAS), increase renal tubular sodium reabsorption and stimulate sympathetic activity. In our study, the concentration of leptin in patients was measured before and after the three-month supplementation with cholecalciferol. There was a significant decrease in leptin concentration from 16.9 ± 1.65 ng/ml to 14.72 ± 1.78 ng/ml (p = 0.029). Manoy et al. assessed the effect of vitamin D on the levels of inflammatory markers (hs-CRP, IL-6) and leptin in patients with osteoarthritis. In this study, patients were supplemented with ergocalciferol at a dose of 40,000 IU every week for six months. There were no significant differences in the concentration of leptin and inflammatory markers [42]. However, this study should take into account the fact that people with chronic inflammatory disease took part in it. Moreover, supplementation with ergocalciferol and cholecalciferol differ from each other. Ergocalciferol has a lower affinity for vitamin D binding protein (VDBP), so its transport to the liver may be limited compared to cholecalciferol. In addition, ergocalciferol has a shorter serum half-life [43]. High serum leptin levels are associated with pathological myocardial hypertrophy and ischemia, an increased risk of serious cardiovascular events, and a poorer prognosis in patients with heart failure [44]. In a study by Mousa et al., cholecalciferol supplementation at a dose of 4000 IU daily for 16 weeks in overweight or obese people with a baseline 25(OH)D3 concentration ≤ 50 nmol/L did not cause significant differences in the concentration of adiponectin and leptin in the serum (p > 0.05) [45]. Research on the role of leptin and its effects on the body is still ongoing.

TMAO is generated from dietary choline, betaine, and L-carnitine. Multiple studies have suggested a correlation between plasma TMAO levels and the risk of CVDs. Its levels positively correlates with ongoing atherosclerosis [46], HF [47], CHD [48] and multivessel disease [49]. High levels TMAO indicate higher risk of atherosclerosis [50], first ischaemic stroke [51], as well as other CVDs and is associated with higher mortality among heart failure patients [52]. Most of the researchers show reverse correlation between VEGF-A level and CHD [53] and worse predictions for CHD patients [54]. Bernhard et al., indicate this relation may not be linear but may be reverted U-shaped [55]. According to their paper our patients are at the highest risk both before and after supplementation. According to other researchers levels after supplementation in our group are observed in healthy controls. As most studies are in contrast to the results of Berhard et al., it rather seems that lower levels of VEGF-A correlates with higher risk of CVDs. Three months of cholecalciferol therapy did not induce any statistically significant changes in serum levels of sST2. Our research results are consistent with the results of Francic et al. They showed that oral cholecalciferol supplementation at a dose of 2800 IU/day for 8 weeks, despite a statistically significant increase in serum 25(OH)D3 concentration of the studied patients [25(OH)D3 (11.3(9.2–13.5) ng/mL; p < 0.001)] compared to placebo, did not change the sST2 level [56].

Sarkar et al. reports that VEGF-A expression is dependent on a biochemical pathway linked to the VDR. VDR activation by vitamin D increases VEGF-A synthesis in vascular endothelial cells [57]. Research shows that the VDR is a transcription factor for the promoter of the gene encoding VEGF-A [58]. VDR is found in many cells, including adipocytes [59] and it seems justified that VEGF-A expression is also stimulated in them by a biochemical mechanism dependent on vitamin D. Biosynthesis of TMAO seems to depend on vitamin D. Obeid et al. show that TMAO plasma levels are significantly lower after cholecalciferol supplementation [60]. Adipose tissue, and more precisely WAT, apart from energy storage, also plays an endocrine role and is the largest gland in obese people [61]. It secretes many hormones, mainly leptin and to a lesser extent tumor necrosis factor α (TNFα) [62]. High levels of secreted TNFα and other pro-inflammatory cytokines indicate the existing inflammation of WAT [63]. Endothelium may be another source of proinflammatory protein synthesis, and this process also appears to depend on leptin [64]. The present study seems to show that vitamin D interrupts this pathological positive feedback mechanism of prolonged inflammation by reducing the serum leptin concentration of patients after three months of cholecalciferol supplementation. In our opinion, this may be accomplished by the inhibitory effect of vitamin D on TNFα secretion by M1 macrophages or by inhibition of the action on lipocytes for the production of leptin. The secretion of inflammatory factors can also be stimulated by TMAO [65]. The effect of cholecalciferol supplementation on the reduction of serum TMAO levels may explain its potential anti-inflammatory effect by reducing TNFα synthesis. In addition, the beneficial effect on adipose tissue results from the increase in VEGF-A concentration in WAT. As a result of angiogenesis in the WAT, there is a better blood supply and its saturation with oxygen [66]. While high levels of VEGF-A may indicate existing inflammation, there is no reason to believe that this is the case since a decrease in pro-inflammatory factors was observed in the patients studied. Mouse models of VEGF-A overexpression in WAT showed better blood supply to this tissue, and the adipocytes themselves showed features of more metabolically active cells [67, 68]. Moreover, VEGF-A reduces the expression of leptin in adipose tissue [69], which may be another part of the mechanism of the observed decrease in leptin levels. On the other hand, in murine models in which VEGF-A levels in WAT are decreased, higher levels of TNFα and leptin are observed [70]. Mahdaviani et al. reported that the thermally and metabolically active BAT adipose tissue is characterized by a higher expression of VEGF-A compared to energy storage WAT [71]. Based on the above data, it can be concluded that the correct level of 25(OH)D3 in the serum is essential for the maintenance of homeostasis in adipose tissue. In our opinion cholecalciferol supplementation in obese patients has a positive effect on adipose tissue and the gut microbiome. This leads to a reduction in the levels of inflammatory factors in the serum and may be responsible for a reduction in the risk of CVDs. Based on the beneficial effects of cholecalciferol supplementation on CVS shown in many studies, we believe that vitamin D may have beneficial clinical implications also in obese patients. Our study has some limitations, but in some respects it is in line with data published by other researchers. A limitation may be the methodological differences between our research and those discussed in the discussion, as well as the relatively small of test group.


The data presented in our article indicate the potential effect of vitamin D on the concentration of some biomarkers in the blood serum related to CVDs. We have shown that cholecalciferol in a dose of 2000 IU/day in obese patients modifies the function of the vascular endothelium and selected parameters of inflammation. Our study provides important and valuable information at the molecular level. The three month vitamin D supplementation was associated with a decrease in TMAO and leptin levels. Supplementation was associated with an increase in NO and VEGF-A. There was no statistically significant change in sST2 concentration. The results of our study are consistent with the results of some researchers, but the data in the literature remain inconclusive. Further studies will verify whether the intervention undertaken by our team is significant in assessing the risk stratification of selected clinical aspects.

Availability of data and materials

The data presented in this study are available on request from the corresponding author.



Brown adipose tissue




Cardiovascular system


Cardiovascular diseases


Coronary heart disease


Endothelium-derived hyperpolarizing factor

eNOS :

Endothelial nitric oxide synthase


Heart failure


Interleukin 6


High-sensitivity C-reactive protein


Myocardial infraction


Non-alcoholic fatty liver disease


Nuclear factor kappa-light-chain-enhancer of activated B cells

nNOS :

Neuronal nitric oxide synthase


Nitric oxide


Renin–angiotensin-aldosterone system


Trimethylamine N-oxide


Vitamin D binding protein


Vascular endothelial growth factor A


Vitamin D receptor


Soluble suppression of tumorigenicity 2


Tumor necrosis factor α


White adipose tissue

25(OH)D3 :

25-Hydroxyvitamin D3


  1. Lugg ST, Howells PA, Thickett DR. Optimal Vitamin D supplementation levels for cardiovascular disease protection. Dis Mark. 2015.

    Article  Google Scholar 

  2. Bae S, Singh SS, Yu H, Lee JY, Cho BR, Kang PM. Vitamin D signaling pathway plays an important role in the development of heart failure after myocardial infarction. J Appl Physiol. 2013;114:979–87.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Dzau VJ, Antman EM, Black HR, Black HR, Hayes DL, Manson JE, Plutzky J, Popma JJ, Stevenson W. The cardiovascular disease continuum validated: clinical evidence of improved patient outcomes. Part I: pathophysiology and clinical trial evidence (risk factors through stable coronary artery disease). Circulation. 2006;114(25):2850–70.

    Article  Google Scholar 

  4. Dadonienė J, Čypienė A, Rinkūnienė E, Badarienė J, Burca J, Sakaitė I, Kalinauskaitė G, Kumpauskaitė V, Laucevičius A. Vitamin D and functional arterial parameters in postmenopausal women with metabolic syndrome. Adv Med Sci. 2016;61(2):224–30.

    Article  Google Scholar 

  5. Tare M, Emmett SJ, Coleman HA, Skordilis C, Eyles DW, Morley R, Parkington H. Vitamin D insufficiency is associated with impaired vascular endothelial and smooth muscle function and hypertension in young rats. J Physiol. 2011;589(19):4777–86.

    Article  CAS  Google Scholar 

  6. Wang TJ, Pencina MJ, Booth SL, Jacques PF, Ingellson E, Lanier K, Benjamin EJ, D’Agostino RB, Wolf M, Vasan RS. Vitamin D deficiency and risk of cardiovascular disease. Circulation. 2008;117(4):503–11.

    Article  CAS  Google Scholar 

  7. Anderson JL, May HT, Horne BD, Bair TL, Hall NL, Carlquist JF, Lappe DL, Muhlestein JB. Relation of vitamin D deficiency to cardiovascular risk factors, disease status, and incident events in a general healthcare population. Am J Cardiol. 2010;106(7):963–8.

    Article  CAS  Google Scholar 

  8. Beveridge LA, Witham MD. Vitamin D and the cardiovascular system. Osteoporos Int. 2013;24:2167–80.

    Article  CAS  PubMed  Google Scholar 

  9. Wortsman J, Matsuoka LY, Chen TC, Lu Z, Holick MF. Decreased bioavailability of vitamin D in obesity. Am J Clin Nutr. 2000;72:690–3.

    Article  CAS  PubMed  Google Scholar 

  10. Florez H, Martinez R, Chacra W, Strickman-Stein N, Levis S. Outdoor exercise reduces the risk of hypovitaminosis D in the obese. J Steroid Biochem Mol Biol. 2007;103:679–81.

    Article  CAS  PubMed  Google Scholar 

  11. Targher G, Bertolini L, Scala L, Cigolini M, Zenari L, Falezza G, Arcaro G. Associations between serum 25-hydroxyvitamin D3 concentrations and liver histology in patients with non-alcoholic fatty liver disease. Nutr Metab Cardiovasc Dis. 2007;17:517–24.

    Article  CAS  PubMed  Google Scholar 

  12. Trayhurn P. Adipocyte biology. Obes Rev. 2007;8(suppl 1):41–4.

    Article  CAS  PubMed  Google Scholar 

  13. Bagchi M, Kim LA, Boucher J, Walshe TE, Kahn CR, D’Amore PA. Vascular endothelial growth factor is important for brown adipose tissue development and maintenance. FASEB J. 2013;27:3257–71.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Aguilar-Valles A, Inoue W, Rummel C, Luheshi GN. Obesity, adipokines and neuroinflammation. Neuropharmacology. 2015;96(A):124–34.

    Article  CAS  PubMed  Google Scholar 

  15. Hajer GR, van Haeften TW, Visseren FL. Adipose tissue dysfunction in obesity, diabetes, and vascular diseases. Eur Heart J. 2008;29(24):2959–71.

    Article  CAS  PubMed  Google Scholar 

  16. Gordon S, Martinez FO. Alternative activation of macrophages: mechanism and functions. Immunity. 2010;32(5):593–604.

    Article  CAS  PubMed  Google Scholar 

  17. Chen ML, Zhu XH, Ran L, Lang HD, Yi L, Mi MT. Trimethylamine-N-oxide induces vascular inflammation by activating the NLRP3 inflammasome through the SIRT3-SOD2-mtROS signaling pathway. J Am Heart Assoc. 2017;6(9): e006347.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Barrea L, Muscogiuri G, Annunziata G, Laudisio D, Alteriis G, Tenore GC, Colao A, Savastano S. A new light on vitamin D in obesity: a novel association with trimethylamine-N-oxide (TMAO). Nutrients. 2019;11:1310.

    Article  CAS  PubMed Central  Google Scholar 

  19. Guarneri F, Custurone P, Papaianni V, Gangemi S. Involvement of RAGE and oxidative stress in inflammatory and infectious skin diseases. Antioxidants (Basel). 2021;10(1):1–14.

    Google Scholar 

  20. Hooper WC. The relationship between inflammation and the anticoagulant pathway: the emerging role of endothelial nitric oxide synthase (eNOS). Curr Pharm Des. 2004;10(8):923–7.

    Article  CAS  PubMed  Google Scholar 

  21. Xiong XQ, Chen WW, Zhu GQ. Adipose afferent reflex: Sympathetic activation and obesity hypertension. Acta Physiol. 2014;210:468–78.

    Article  CAS  Google Scholar 

  22. Braile M, Marcella S, Cristinziano L, Galdiero MR, Modestino L, Ferrara AL, Varricchi G, Marone G, Loffredo S. VEGF-A in cardiomyocytes and heart diseases. Int J Mol Sci. 2020;21(15):5294.

    Article  CAS  PubMed Central  Google Scholar 

  23. Pascual-Figal DA, Januzzi JL. The biology of ST2: the international ST2 consensus panel. am J Cardiol. 2015;115(7 supl.):3B-7B.

    Article  CAS  Google Scholar 

  24. Ip C, Luk KS, Yuen VLC, Chiang L, Chan CK, Ho K, Gong M, Lee TTL, Leung KSK, Roever L, Bazoukis G, Lampropoulos K, Li KHC, Tse G, Liu T. International Health Informatics Study (IHIS) Network. Soluble suppression of tumorigenicity 2 (sST2) for predicting disease severity or mortality outcomes in cardiovascular diseases: a systematic review and meta-analysis. Int J Cardiol Heart Vasc. 2021;37:100887.

    PubMed  PubMed Central  Google Scholar 

  25. Gotsman I, Shauer A, Zwas DR, et al. Vitamin D deficiency is a predictor of reduced survival in patients with heart failure; vitamin D supplementation improves outcome. Eur J Heart Fail. 2012;14(4):357–66.

    Article  CAS  PubMed  Google Scholar 

  26. Ozcan OU, Gurlek A, Gursoy E, Gerede DM, Erol C. Relation of vitamin D deficiency and new-onset atrial fibrillation among hypertensive patients. J Am Soc Hypertens. 2015;9(4):307–12.

    Article  CAS  PubMed  Google Scholar 

  27. Bjelakovic G, Gluud LL, Nikolova D , et al. Vitamin D supplementation for prevention of mortality in adults. Cochrane Database Syst Rev. 2014;10(1):Article ID CD007470.

  28. Sun Q, Shi L, Rimm EB, Giovannucci EL, Hu FB, Manson JE, Rexrode KM. Vitamin D intake and risk of cardiovascular disease in US men and women. Am J Clin Nutr. 2011;94(2):534–42.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Modarresi-Ghazani F, Hejazi ME, Gharekhani A, Entezari-Maleki T. Role of vitamin D in cardiovascular disease. Arch Iran Med. 2016;19(5):359–62.

    PubMed  Google Scholar 

  30. Touskova V, Haluzik M. Insulin resistance and nitric oxide: molecular mechanisms and pathophysiological associations. Cesk Fysiol. 2011;60(2):40–7.

    CAS  PubMed  Google Scholar 

  31. Al-Daghri NM, Bukhari I, Yakout SM, Sabico S, Khattak MNK, Aziz I, Alokail MS. Associations of serum nitric oxide with vitamin D and other metabolic factors in apparently healthy adolescents. Biomed Res Int. 2018;1489132:1–7.

    Article  Google Scholar 

  32. Huang Z, Liu L, Huang S, Li J, Feng S, Huang N, Ai Z, Long W, Jiang L. Vitamin D (1,25-(OH)2D3) improves endothelial progenitor cells function via enhanced NO secretion in systemic lupus erythematosus. Cardiol Res Pract. 2020;6802562:1–8.

    Google Scholar 

  33. Andrukhova O, Slavic S, Zeitz U, Riesen SC, Heppelmann MS, Ambrisko TD, Markovic M, Kuebler WM, Erben RG. Vitamin D is a regulator of endothelial nitric oxide synthase and arterial stiffness in mice. Mol Endocrinol. 2014;28(1):53–64.

    Article  Google Scholar 

  34. Tran V, De Silva TM, Sobey CG, Lim K, Drummond GR, Vinh A, Jelinic M. The vascular consequences of metabolic syndrome: rodent models, endothelial dysfunction, and current therapies. Front Pharmacol. 2020;11:1–10.

    Article  Google Scholar 

  35. Wolf ST, Jablonski NG, Ferguson SB, Alexander LM, Kenney WL. Four weeks of vitamin D supplementation improves nitric oxide-mediated microvascular function in college-aged African Americans. Am J Physiol Heart Circ Physiol. 2020;319(4):906–14.

    Article  Google Scholar 

  36. Akbari M, Ostadmohammadi V, Lankarani KB, Tabrizi R, Kolahdooz F, Heydari ST, Kavari SH, Mirhosseini N, Mafi A, Dastorani M, Asemi Z. The effects of vitamin D supplementation on biomarkers of inflammation and oxidative stress among women with polycystic ovary syndrome: a systematic review and meta-analysis of randomized controlled trials. Horm Metab Res. 2018;50(4):271–9.

    Article  CAS  Google Scholar 

  37. Zeng R, et al. Association of leptin levels with pathogenetic risk of coronary heart disease and stroke: a meta-analysis. Arquivos brasileiros de endocrinologia e metabologia. 2014;58(8):817–23.

    Article  PubMed  Google Scholar 

  38. Soderberg S, Stegmayr B, Stenlund H, Sjostrom LG, Agren A, Johansson L, et al. Leptin, but not adiponectin, predicts stroke in males. J Internal Med. 2004;256(2):128–36.

    Article  CAS  PubMed  Google Scholar 

  39. Liu J, Butler KR, Buxbaum SG, Sung JH, Campbell BW, Taylor HA. Leptinemia and its association with stroke and coronary heart disease in the Jackson Heart Study. Clin Endocrinol. 2010;72(1):32–7.

    Article  CAS  Google Scholar 

  40. Wallace AM, McMahon AD, Packard CJ, Kelly A, Shepherd J, Gaw A, et al. Plasma leptin and the risk of cardiovascular disease in the west of Scotland coronary prevention study (WOSCOPS). Circulation. 2001;104(25):3052–6.

    Article  CAS  Google Scholar 

  41. Lu SC, Akanji AO. Leptin, obesity, and hypertension: a review of pathogenetic mechanisms. Metab Syndr Relat Disord. 2020;18(9):399–405.

    Article  CAS  Google Scholar 

  42. Manoy P, Yuktanandana P, Tanavalee A, Anomasiri W, Ngarmukos S, Tanpowpong T, Honsawek S. Vitamin D supplementation improves quality of life and physical performance in osteoarthritis patients. Nutrients. 2017;9(8):1–13.

    Article  Google Scholar 

  43. Jones KS, Assar S, Harnpanich D, Bouillon R, Lambrechts D, Prentice A, Schoenmakers I. 25(OH)D2 half-life is shorter than 25(OH)D3 half-life and is influenced by DBP concentration and genotype. J Clin Endocrinol Metab. 2014;99(9):3373–81.

    Article  CAS  Google Scholar 

  44. Falcao-Pires I, Castro-Chaves P, Miranda-Silva DI, Lourenco A, Leite-Moreira AF. Physiological, pathological and potential therapeutic roles of adipokines. Drug Discov Today. 2012;17:880–9.

    Article  CAS  Google Scholar 

  45. Mousa A, Naderpoor N, Wilson K, Plebanski M, de Courten MPJ, Scragg R, de Courten B. Vitamin D supplementation increases adipokine concentrations in overweight or obese adults. Eur J Nutr. 2020;59(1):195–204.

    Article  CAS  Google Scholar 

  46. Geng J, et al. Trimethylamine N-oxide promotes atherosclerosis via CD36-dependent MAPK/JNK pathway. Biomed Pharmacother Biomedecine pharmacotherapie. 2018;97:941–7.

    Article  CAS  PubMed  Google Scholar 

  47. Dong Z, et al. The correlation between plasma trimethylamine N-oxide level and heart failure classification in northern Chinese patients. Ann Palliat Med. 2020;9(5):2862–71.

    Article  PubMed  Google Scholar 

  48. Dong Z, Liang Z, Guo M, Hu S, Shen Z, Hai X. The association between plasma levels of trimethylamine N-oxide and the risk of coronary heart disease in Chinese patients with or without type 2 diabetes mellitus. Dis Mark. 2018;2018:1578320.

    Article  CAS  Google Scholar 

  49. Zhou P, Li J, Zhou J. Relation of circulating trimethylamine n-oxide with coronary atherosclerotic burden in patients with ST-segment elevation myocardial infarction. Am J Cardiol. 2019;123(6):894–8.

    Article  CAS  PubMed  Google Scholar 

  50. Ding L, Chang M, Guo Y, Zhang L, Xue C, Yanagita T, Zhang T, Wang Y. Trimethylamine-N-oxide (TMAO)-induced atherosclerosis is associated with bile acid metabolism. Lipids Health Dis. 2018;17(1):286.;PMCID:PMC6300890.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  51. Rexidamu M, Li H, Jin H, Huang J. Serum levels of trimethylamine-N-oxide in patients with ischemic stroke. Biosci Rep. 2019;39(6):BSR20190515.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  52. Tang WH, Wang Z, Fan Y, Levison B, Hazen JE, Donahue LM. Prognostic value of elevated levels of intestinal microbe-generated metabolite trimethylamine-N-oxide in patients with heart failure: refining the gut hypothesis. J Am Coll Cardiol. 2014;64(18):1908–14.

    Article  CAS  PubMed  Google Scholar 

  53. Huang A, et al. Serum VEGF: diagnostic value of acute coronary syndrome from stable angina pectoris and prognostic value of coronary artery disease. Cardiol Res Pract. 2020.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Han X, et al. Serum VEGF spredicts worse clinical outcome of patients with coronary heart disease after percutaneous coronary intervention therapy. Med Sci Monit. 2015;21:3247–51.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  55. Kaess BM, et al. Circulating vascular endothelial growth factor and the risk of cardiovascular events. Heart. 2016;102(23):1898–901.

    Article  PubMed  Google Scholar 

  56. Francic V, Keppel M, Schwetz V, Trummer C, Pandis M, Borzan V, Grübler MR, Verheyen ND, Kleber ME, Delgado G, Moissl AP, Dieplinger B, März W, Tomaschitz A, Pilz S, Obermayer-Pietsch B. Are soluble ST2 levels influenced by vitamin D and/or the seasons? Endocr Connect. 2019;8(6):691–700.

    Article  CAS  Google Scholar 

  57. Sarkar S, et al. Vitamin D regulates the production of vascular endothelial growth factor: a triggering cause in the pathogenesis of rheumatic heart disease? Med Hypoth. 2016;95:62–6.

    Article  CAS  Google Scholar 

  58. Cardus A, et al. 1,25-Dihydroxyvitamin D3 regulates VEGF production through a vitamin D response element in the VEGF promoter. Atherosclerosis. 2009;204(1):85–9.

    Article  CAS  PubMed  Google Scholar 

  59. Li J, et al. 1alpha,25-Dihydroxyvitamin D hydroxylase in adipocytes. J Steroid Biochem Mol Biol. 2008;112(1–3):122–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  60. Obeid R, et al. Plasma trimethylamine-N-oxide following supplementation with vitamin D or D plus B vitamins. Mol Nutr Food Res. 2017.

    Article  PubMed  Google Scholar 

  61. Coelho M, et al. Biochemistry of adipose tissue: an endocrine organ. Arch Med Sci. 2013;9(2):191–200.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  62. Kershaw EE, Flier JS. Adipose tissue as an endocrine organ. J Clin Endocrinol Metab. 2004;89(6):2548–56.

    Article  CAS  PubMed  Google Scholar 

  63. Wang L, et al. Triglyceride-rich lipoprotein lipolysis releases neutral and oxidized FFAs that induce endothelial cell inflammation. J Lip Res. 2009;50(2):204–13.

    Article  CAS  Google Scholar 

  64. Gainsford T, Alexander WS. A role for leptin in hemopoieses? Mol Biotechnol. 1999;11(2):149–58.

    Article  CAS  PubMed  Google Scholar 

  65. Farmer N, et al. Neighborhood environment associates with trimethylamine-N-oxide (TMAO) as a cardiovascular risk marker. Int J Environ Res Public Health. 2021;18(8):4296.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  66. Elias I, et al. Adipose tissue overexpression of vascular endothelial growth factor protects against diet-induced obesity and insulin resistance. Diabetes. 2012;61(7):1801–13.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  67. During MJ, et al. Adipose VEGF links the white-to-brown fat switch with environmental, genetic, and pharmacological stimuli in male mice. Endocrinology. 2015;156(6):2059–73.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  68. Sun K, et al. Brown adipose tissue derived VEGF-A modulates cold tolerance and energy expenditure. Mol Metab. 2014;3(4):474–83.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  69. Bekhite MM, et al. Hypoxia, leptin, and vascular endothelial growth factor stimulate vascular endothelial cell differentiation of human adipose tissue-derived stem cells. Stem Cells Dev. 2014;23(4):333–51.

    Article  CAS  PubMed  Google Scholar 

  70. Sung H-K, et al. Adipose vascular endothelial growth factor regulates metabolic homeostasis through angiogenesis. Cell Metab. 2013;17(1):61–72.

    Article  CAS  PubMed  Google Scholar 

  71. Mahdaviani K, et al. Autocrine effect of vascular endothelial growth factor-A is essential for mitochondrial function in brown adipocytes. Metab Clin Exp. 2016;65(1):26–35.

    Article  CAS  PubMed  Google Scholar 

Download references


Not applicable.


The present work was supported by the Department of Pharmacology and Therapeutics, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Torun, Poland.

Author information

Authors and Affiliations



M.O., Ł.W., A. F-M. contributed to data analysis, interpretation of findings, and drafting the article. M.O. and M.W. participated in data collection, critical revision of the article, and final approval. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Mateusz Ozorowski.

Ethics declarations

Ethics approval and consent to participate

The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Institutional Ethics Committee of Nicolaus Copernicus University Collegium Medicum (Approval Number KB48/2019 of 29.01.2019).

Consent for publications

Not applicable.

Competing interests

The authors declare no conflict of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ozorowski, M., Wiciński, M., Wróbel, Ł. et al. Cholecalciferol supplementation lowers leptin and TMAO but increases NO and VEGF-A levels in obese vitamin D deficient patients: Is it one of the potential cardioprotective mechanisms of vitamin D?. Nutr Metab (Lond) 19, 31 (2022).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: