High calcium causing heart attacks? Vitamin K to the rescue!

You’ve likely heard the media furor around a recent finding that use of calcium supplements is associated with a higher risk of heart attack, based on a study published in the British Medical Journal a month or so ago. Many people I’ve heard from are surprised and alarmed by this news — but unfortunately, it’s not news to me. In my 2000 book, Better Bones, Better Body, on p. 248, I wrote, “Over and over we are told to consume adequate calcium. What we are not told, however, is that we also need… other bone building nutrients. They also forget to tell us that it can actually be harmful to consume high levels of calcium without its companion nutrients.”

Calcium doesn’t magically travel straight from your yogurt to your bones, as some advertisers would have you believe (I discuss this in my article The calcium myth). Instead, it needs companion nutrients that help with absorption, utilization, and regulation of calcium in not only the bones, but also the blood, organs, and other tissues. The fact that vitamin D is crucial for calcium absorption is becoming better recognized by researchers and the public alike thanks to an avalanche of research on vitamin D, but another vitamin — vitamin K — is, in my opinion, the “next big breakthrough” for bone (and overall) health. You see, vitamin K (specifically K2 in the form of MK-7) has a very critical role to play in binding calcium to the tissues that need it, particularly the bones. And if vitamin K is present and doing its job, calcium meant for the bones and teeth doesn’t wind up being calcified in the arteries, setting the stage for heart disease.

But heart disease is not the only health problem that arises with excess calcium — it’s just the most frightening possibility out there. High calcium intake interferes with the absorption or utilization of other nutrients, including manganese, magnesium, iron, zinc, and phosphorus (most of which, by no coincidence, are key minerals involved in keeping bone strong and flexible). And calcium and magnesium work in concert so that increasing your calcium levels without simultaneously increasing magnesium can promote calcium deposits in the joints or kidneys, leading to arthritis and kidney stones! In a nutshell, supplementing with high levels of calcium alone tips the scales not toward better, healthier bones and bodies, but away from them.

Fortunately, rebalancing those scales is easy! We need to recognize, first of all, that we don’t really need  the very high  calcium intakes that we’re constantly told will strengthen our bones, and second, that we’d fare better with a comprehensive nutritional approach to osteoporosis and overall health that includes, at the very minimum, vitamin D, magnesium, and above all vitamin K2 to balance the body’s absorption, metabolism, and utilization of calcium.

Also, there is a large body of scientific research on vitamin K and the prevention of arterial calcification.Should you be interested in knowing more, take a look at my article, “Vitamin K: the overlooked bone builder and heart protector.”

 

References

Bolland, M.J., Avenell, A., Baron, J.A., et al. 2010. Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: Meta-analysis. BMJ;341:c3691.

Cleland, J.G.F., Witte, K., Steel, S. 2010. Calcium supplements in people with osteoporosis. BMJ;341:c3856.

 

Can vitamin D compete with bone drugs?

At the Center for Better Bones, we are constantly thinking about fracture reduction and looking for data to help us compare the fracture-reduction potential of bone drugs and natural therapies. Recently, two very interesting “meta-analysis” reviews came across my desk. One review assessed the fracture-reduction potential of bisphosphonate drugs, and the other did the same for vitamin D. At the end of the day, vitamin D was shown to reduce more fractures than the popular bisphosphonate drugs.

Let’s look at the details.

The bisphosphonate drug studies. The bone drug overview analysis pooled data from 31 bisphosphonate drug studies, involving a total of 376,134 postmenopausal women. Twenty of these studies were the gold-standard placebo-controlled, randomized research trials, and the other eleven studies used fracture data from large clinical databases.

The object of this meta-analysis was to see if the bisphosphonate fracture-reduction rate reported from the randomized, highly controlled research trials was achievable among real world patients in the doctor’s office. The answer was yes. The authors of this article, published in Osteoporosis International, were delighted to find the bone medications yielded “real world” fracture reduction, just as they did in the highly controlled research trials. Overall, the total fracture reduction potential of this leading class of osteoporosis drugs was 22%.

The vitamin D studies. How powerful is vitamin D as a fracture-reduction agent? To answer this question, researchers conducted a similar meta-analysis of clinical trials investigating vitamin D and fracture. They summarized the findings of 12 state-of-the-art randomized control trials, involving 19,114 individuals 60 years of age and older.

This analysis found that, “A vitamin D dose of 700–800 IU a day reduced the relative risk of hip fracture by 26% and any non-vertebral fracture by 23%.” Lower dose vitamin D was not effective at reducing fractures, and no clinical trials had looked at the fracture-reduction power of higher dose vitamin D.

In other studies where participants supplement to achieve a therapeutic blood level of vitamin D, which is 32 ng/mL, fracture reduction has been seen to exceed 50%.
Supplementing with vitamin D is a safe, natural, inexpensive, way to reduce needless osteoporotic fractures and support your overall health. And, according to these two scientific meta-analyses, in adequate doses vitamin D may well be more effective than today’s most popular osteoporosis drugs. Remember, you can always make vitamin D in your body by exposing your skin to the sun as well. Here are our Better Bones guidelines for sunlight exposure:

• Short periods, 15-20 minutes daily, of near full-body exposure (without sunscreen) are best for light-skinned people.
• Use sunscreen after this initial period if necessary to avoid a sunburn.
• The useful ultraviolet rays are strongest between 10 am and 2 pm.
• Very dark-skinned people require 4-6 times more sunlight exposure than light-skinned people.
• In northern or southern latitudes distant from the Equator, longer exposure is needed, especially during the spring and fall.
• In climates of the northern or southern latitudes distant from the Equator, very little or no vitamin D is produced in the skin during the winter months.

If you’d like to assess your fracture risk, see our fracture risk and bone health profile.

 

References:

Bischoff-Ferrari, HA et al. 2005. Fracture prevention with vitamin D supplementation: A meta-analysis of randomized controlled trials. JAMA, 293(18): 2257-2264.

Brown, SE. 2008. Vitamin D and fracture reduction: An evaluation of the existing research. Alternative Medicine Review, 13(1):21-33.

Wilkes, MM et al. 2010. Bisphosphonates and osteoporotic fractures: A cross-design synthesis of results among compliant/persistent postmenopausal women in clinical practice versus randomized controlled trials. Osteoporosis International, 21(4):679-688.

 

New IOM vitamin D recommendations — baby steps and missteps

You may have heard recently all the news stories that talked about the Institute of Medicine’s (IOM) new guidelines for vitamin D and calcium. These guidelines were updates from those issued in 1997, and the reason for this fuss was that people were surprised and confused by the recommendations related to vitamin D. The message spread far and wide in the media was, “People really don’t need that much vitamin D,” which dismayed many people who’d been using supplements. Worse, some news outlets implied that taking any vitamin D supplements wasn’t just unnecessary, but could even be harmful.

At the heart of the confusion is the fact that these guidelines attempt to establish values for basic nutritional adequacy (meeting the basic needs of 97–98% of the population), not optimum nutrient intake. “Adequate” and “optimum” are very different things — as different as “survival” and “health”! Unfortunately, the way it was presented to the media and the public was “this amount is all you need to be healthy,” and that message just isn’t supported by all of the ongoing research — much of which, sadly, wasn’t included in the IOM’s assessment.

So we at the Center for Better Bones see the current IOM adjustment to the vitamin D Dietary Reference Intake (DRI) as representing both good and bad news. The good news is that we’ve taken baby steps forward in tripling and doubling the RDA (Recommended Daily Allowance) for adults and children and doubling the safe upper level; the bad news is that the message offers false assurance — and maybe even some unnecessary fears — to the general public about their vitamin D intake.

The “baby steps” I referred to are as follows:

1. Raising the Recommended Daily Allowances
The recommendations triple the RDA for individuals age 1 to 70, from 200 IU to 600 IU, and they double the RDA for elderly older than 70 (from 400 IU to 800 IU). I’m thrilled that they recognized that the original recommendations weren’t sufficient, but disappointed that this is as far as they went, given that all the research I’ve seen shows clearly that all people need much, much more than these recommended amounts to be truly healthy.

2. Raising the “Tolerable Upper Limits”
Here again the IOM moved in the right direction: they raised the safe upper limit of vitamin D from 2000 IU to 4000 IU per day for individuals older than 9 years, and also set the upper limit higher for younger children based on their age. We’ve long known that doses over 2000 IU are perfectly safe, and while we often find that even doses above 4000 IU can be beneficial to those who need it, the recommendation moves us forward and confirms the safety of 4000 IU vitamin D for the population as a whole.

Here’s where the IOM missed the boat.

1. Establishing 20 ng/mL as “the level that is needed for good bone health for practically all individuals.”
To put it politely, this conclusion is incorrect. (If I were impolite, I’d call it ridiculous.)  In 2009, Bischoff–Ferrari and colleagues published two separate meta-analyses documenting that 20 ng/mL was not sufficient for either fracture or fall reduction. Furthermore, decades of research have established conclusively that the minimal serum 25(OH)D level conducive to bone health is 30–32 ng/mL. It is noteworthy that both the International Osteoporosis Foundation and Osteoporosis Canada support this higher target level for bone health.

2. Basing the vitamin D intake guidelines solely upon the bone health benefits of vitamin D
In their review of the scientific studies, the IOM panel concluded that the evidence supported a role for vitamin D exclusively in bone health. They did not examine a vast body of new research supporting the health benefits of vitamin D because much of it wasn’t the same sort of double-blind, placebo-controlled trials used to prove efficacy of drugs. But there’s plenty of evidence — solid evidence — associating higher vitamin D levels with reductions in the rates of cancer, heart disease, diabetes, multiple sclerosis, and other chronic diseases. These studies clearly indicate that vitamin D levels higher than the minimum required for basic bone health are needed for disease prevention. In fact, a panel of 41 expert vitamin D researchers and medical practitioners has set the evidence-based vitamin D target level at 40–60 ng/mL, a level that we at the Center for Better Bones concur with. But the IOM chose to overlook this data.

3. Concluding that most North Americans are receiving enough vitamin D and need no additional supplementation
This is what’s called “circular logic” — by setting a very low level for vitamin D adequacy (20 ng/mL), of course they conclude that very few people are deficient! Yet vitamin D levels in this country are well below the therapeutic target set by major vitamin D researchers (40–60 ng/mL), and they are declining. According to the NHANES national survey the average vitamin D level has dropped, from 30 ng/mL in 1988–1994 to 24 ng/mL in 2001–2004. The percentage of those below 10 ng/mL has increased from 2% to 6%, and the percentage with levels of 30 or above has decreased from 45% to 23%.

Moving forward — don’t wait another decade for the IOM to catch up

We evolved in abundant sunlight, and our genetic coding reflects the longstanding importance of vitamin D — there are nearly 2800 binding sites for the vitamin D receptor across the length of our genome. A vitamin D level of 40–60 ng/mL would approximate that of our ancestors and — not coincidentally — levels associated with protection from today’s most problematic health issues. Obtaining this more natural vitamin D blood level is easy and safe to do — simply have your vitamin D level tested and then supplement with appropriate vitamin D3 (or sunlight) to reach the target 40–60 ng/mL level. In the end, it’s your health and your life. You could wait another decade for the IOM to seriously review the full scientific data on vitamin D, or you can move forward by raising your awareness and drawing your own conclusions!

 

References:

Adit, A., et al. 2009. Demographic differences and trends of vitamin D insufficiency in the US population, 1988-2004. Arch. Intern. Med., 169 (6), 626–632. URL:http://archinte.ama-assn.org/cgi/content/full/169/6/626 (accessed 12.08.2010).
Baggerly, C. 2010. Grassroots Health | Vitamin D action – GRH Recommendations. URL: http:// grassrootshealth.net/recommendation (accessed 12.08.2010).

Bischoff-Ferrari, H.A., Willett, W.C., et al. 2009. Prevention of nonvertebral fractures with oral vitamin D and dose dependency: A meta-analysis of randomized controlled trials. Arch. Intern. Med., 169(6), 551–561. URL: http://archinte.ama-assn.org/cgi/content/full/169/6/551 (accessed 12.08.2010).

Bischoff-Ferrari, H.A., Dawson-Hughes, B., et al. 2009. Fall prevention with supplemental and active forms of vitamin D: A meta-analysis of randomized controlled trials. BMJ, 339, b3692. URL: http://www.bmj.com/content/339/bmj.b3692.full(accessed 12.08.2010).

Dawson-Hughes, B., et al. 2010. IOF position statement: Vitamin D recommendations for older adults. Osteoporos. Int., 21 (7), 1151–1154. URL:http://www.springerlink.com/content/nn0577u6826418w7 (accessed 12.08.2010).

Ramagopalan, S., et al. 2010. A ChIP-seq defined genome-wide map of vitamin D receptor binding: Associations with disease and evolution. Genome Res., 20 (10), 1352–1360. URL; http://genome.cshlp.org/content/20/10/1352.long (accessed 09.01.2010).

 

Another great reason to look at Vitamin D – it protects against flu!

There’s been so much information this fall about flu, particularly swine flu, that it’s hard to make sense of it all. But one piece of information that I think gets missed in all the discussion is the importance of vitamin D in preventing influenza infections and boosting immunity. Research is accumulating about the relationship between flu susceptibility and vitamin D levels, and it’s showing just how important it is to keep vitamin D levels in the 50-80 ng/mL range.

Since the flu season is upon us, and especially since swine flu vaccination programs are moving much more slowly than the virus itself, it seems reasonable to hedge your bets and take in sufficient vitamin D to reach the suggested protective vitamin D blood level of 50 to 80 ng/mL 25(OH)D. This represents a vitamin D blood concentration consistent with that obtained from abundant natural summertime sunlight exposure. The amount of vitamin D needed to reach this ideal blood level varies from individual to individual, depending on sunlight exposure, vitamin D reserves, skin color, body fat, age, and the like — and it’s important that you are aware that at this time of year, if you live in northern regions of the country, you can’t rely on sunlight to provide you with adequate vitamin D.

To summarize all the recent data, I have written a new article that details all the new findings about vitamin D and influenza that I encourage you to read. And I encourage you to find out what your vitamin D status is and determine whether you need to find ways to boost your intake.

 

More support for the link between vegetables and good bone health

For years at the Center for Better Bones, we have been touting the bone-preserving benefits of a diet high in alkalizing fruits, vegetables, nuts, seeds, and spices. This important component of the Alkaline for Life® diet is a great way to create abundant bone-protecting alkaline reserves. And there are fantastic side benefits, too, because this wholesome eating pattern also provides an array of vital antioxidants, including essential carotenoids from yellow, orange, and even some green vegetables and fruits. Recent research confirms that these types of potent antioxidants reduce inflammation and, as a result, substantially reduce fracture risk.

A 2009 study published in the Journal of Bone and Mineral Research reports on the results of a 17-year follow-up study of nearly 1,000 men and women (average age: 75). Researchers correlated carotenoid intake with incidence of hip and non-vertebral fracture. Of the people they studied, those with the highest total carotenoid intake had a reduced risk of hip fracture compared to individuals with lower intakes of carotenoids. And even better, individuals with higher intakes of a specific carotenoid — lycopene — also had a reduced risk of both hip and all non-vertebral fractures. Note that lycopene content is particularly high in tomatoes and tomato products, and has been found to be generally protective against other disorders including prostate cancer.

So take it from these researchers: make sure to eat a balanced diet with plenty of carotenoid-rich fruits and veggies. They’re good for just about every aspect of your health.

 

Reference:

Sahni, S, Hannan, MT, Blumberg, J, et al. 2009. Protective effect of total carotenoid and lycopene intake on the risk of hip fracture: A 17-year follow-up from the Framingham Osteoporosis Study. Journal of Bone and Mineral Research, 24(6):1086-1094.

 

A note about certain brands of packaged prunes

Some of my readers might be worried after hearing about a safety alert from the FDA regarding prunes and dried plums contaminated with lead. I want to reassure you that this warning does not concern the prunes from California found in most US supermarkets that we recommend for bone health; instead, it refers to candied, salted, or pickled prunes imported from Asia, products that are generally found in Asian and Hispanic specialty markets. The Texas Department of State Health Services has a list of affected plum products. If you have any of the brands listed on this warning in your  pantry and you haven’t yet used them, discard them immediately; if you’ve already eaten prunes from the listed products, contact your healthcare provider about getting your blood lead levels tested. If you are a regular consumer of imported plum or prune products, be sure to check the above-linked website to ensure your favorite brands are not on the list. You may also want to wait to consume this type of product until the source of the lead contamination has been identified and the matter resolved.

Thankfully, the FDA has emphasized that domestic plums and prunes are not included in this warning, so you can continue to enjoy the bone-building power of domestic prunes in safety. But I’d also like to stress that the imported prune products are a different prune species than the prunes used in the clinical studies, and they may not have exactly the same bone health benefits as the California prunes used in the studies I’ve discussed in earlier blogs on prunes and bone health. So if you’re eating prunes for bone health, our recommendation at the Center for Better Bones is to stick with domestic California dried plums (prunes). (PS an excellent source of organic California prunes can be found at www.OrganicPrunes.com)

 

Parathyroid hormone and magnesium: when “normal” is not always a good thing

This week, I’m at the 2009 national meeting of the American Society for Bone and Mineral Research in Denver, Colorado, learning about the most recent findings in bone research. I wanted to pass along an intriguing bit of information about magnesium deficiency and bone health.

If you’ve been following our work at the Center for Better Bones, you know that I often suggest clients be tested for both vitamin D and parathyroid hormone (PTH) levels. This is because low vitamin D levels can lead to high PTH, a condition that depletes bone.

Here’s how it works: when vitamin D is deficient, we cannot absorb enough calcium from our food to keep our blood calcium levels high enough to support our health. To achieve the necessary blood calcium level, the parathyroid gland releases PTH, which breaks down bone to release stored calcium for transfer into the blood. If this bone breakdown action continues over time, excessive bone loss can occur. In these cases, appropriate supplementation with vitamin D increases calcium absorption from food, which reduces the production of PTH. Normal PTH levels prevent excessive bone loss.

So when can a normal PTH level be a bad thing? When it’s caused by magnesium deficiency! People who are deficient in magnesium do not produce parathyroid normally even if their vitamin D levels are very low. I have seen such cases at the Center for Better Bones, where a person comes to me with low vitamin D status and yet has normal PTH.

In these cases, supplementing with vitamin D will help, but the magnesium deficiency needs to be addressed, too. Magnesium supports bone health on many levels, including stimulating the production of the bone-preserving hormone calcitonin and properly forming calcium crystals in bone. The best way to regulate production of PTH is by providing the body with the nutrients it needs to function well — especially vitamin D and magnesium. With ample nutrition, your body will naturally maintain healthy blood calcium levels while building strong bone — and your PTH will stay at a normal level for the right reasons!

Update on prunes reversing bone loss

It is September 13, 2009, and I am at the largest U.S. meeting of bone researchers (the American Society for Bone and Mineral Research meetings in Denver), and I am pleased to give you a follow-up report on prunes and their amazing ability to reverse bone loss.

 

At this year’s meeting, Professor Bahram Arjmandi and colleagues presented hot-breaking research findings on their one-year human trial testing the potential of prunes to reverse bone loss in postmenopausal women. As you might recall from earlier blogs, Dr. Arjmandi is studying 144 osteopenic postmenopausal women, simply giving them 100 grams of dried prunes daily (10-12 prunes each day) and looking for changes in bone mineral density.

 

The early data is in, and it looks good! The first data from the year-long trial was presented today at the ASBMR Meeting, and the findings include a significant increase in ulna and spine bone mineral density in the women who ate the prunes. As Dr. Arjmandi and colleagues write, “The findings of this one-year study confirm our earlier observation that dried plum has the ability to reverse bone loss.”

 

While the prune-associated hip bone density changes are not yet tabulated, Dr. Arjmandi has high expectations. Previously, he reported several cases showing hip bone density increases from prunes to be even greater than the spinal density gains.

 

Needless to say, I will keep you posted on the hip density increases as they are published. In the meantime, why not share with me and all readers your favorite recipes for adding 10-12 prunes to your daily diet?

 

Vitamin D is more important than calcium

Recently, data from a study of 10,000 Americans supported once again our contention that vitamin D is more important to bone health than is calcium. Even more, this new research suggests that high calcium intakes only aid bone density in those with very low vitamin D status.

Data from the U.S. National Health and Nutrition Examination Survey (NHANES III) published in early 2009, found that calcium intakes of 566 mg per day among women and 626 mg per day among men are likely adequate for those not burdened with low vitamin D levels. Among women only in those very low vitamin D levels (20 ng/mL or less) was there a positive association between calcium intake and bone density. Among women with a greater than 20 ng/mL vitamin D level, a calcium intake of over 566 mg per day was not associated with better bone density than that of women on just 566 mg calcium. Among men, calcium intake was not associated with bone density at any level of vitamin D studied.

So, if we need less calcium than previously thought, a good next question is, “Does higher calcium intake really prevent fractures, anyway?” The authors of this study answer that very question — and their answer is no. Summarizing the findings of more than a dozen large studies, they note the clear lack of association between calcium intake and osteoporosis fracture risk. In fact, a recent, large meta-analysis found higher calcium intakes to actually increase hip fracture risk. For further discussion of these recent findings on calcium intake and fracture see my blog post, “Higher calcium intake does not prevent fractures.”

 

Reference:

Bischoff-Ferrari, HA, et al. 2009. Dietary calcium and serum 25-hydroxyvitamin D status in relation to BMD among U.S. adults. J of Bone Miner Res, 24(5):935-942.

Weak bones in vegetarians?

You might have seen the recent news headlines proclaiming that “Vegetarian Diet Weakens Bones.” This headline, which was published by news sources all around the world, stemmed from an overview analysis (known as a “meta-analysis”) of nine published studies which compared the bone density of vegetarians and omnivores. From the way the news headline was written, you would think that the researchers had found compelling evidence that vegetarians had weaker bones, lower bone density, and increased risk of fracture. The research findings, however, found that vegetarians as a group had only a slightly lower bone density than omnivores and that this difference was neither clinically significant nor likely to result in increased fracture risk. Once again, the wise consumer is advised to look beyond the headlines and sort research facts from journalistic fiction.

 

The story for vegans (vegetarians who eat no flesh foods nor consume any animal products such as eggs or dairy) is a different issue. This new meta-analysis, as in previous individual studies, found that vegans exhibit significantly lower bone density than either vegetarians or omnivores. Vegans have also been noted to have lower body weight and reduced intakes of protein and calcium.

 

And what about the fracture risk of vegetarians and vegans? At the Center for Better Bones, our focus is on fracture risk, not bone density, and while this new study did not address fracture risk, other studies have done so. For example, in 2007, the large European EPIC–Oxford study reported the risk of fracture to be similar for meat eaters, fish eaters, and vegetarians, whereas vegans as a group had a 30% increased risk of fracture. I suspect that low body weight combined with sub-optimal intakes of protein, calcium, and bone-building minerals place vegans at higher risk of fracture, even though they, as other vegetarians, likely have a reduced acid load. This line of thinking is supported by the additional EPIC-Oxford finding that vegans who consumed more calories and at least 525 mg of calcium per day had a fracture rate nearly similar to egg- and milk-eating vegetarians and omnivores.

 

References:

Ho-Pham, LT, Nguyen, ND, Nguyen, TV. 2009. Effect of vegetarian diets on bone mineral density: A Bayesian meta-analysis. Am J Clin Nutr 90:1-8.

Appleby, P, Roddam, A, Allen, N and Key, T. 2007. Comparative fracture risk in vegetarians and nonvegetarians in EPIC-Oxford. Eur J Clin Nutr 61:1400-06.