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Tips to maintain Vitamin D
Dr. Susan E. Brown

5 Vitamin D Tips to Use Today

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Almost every day it seems like researchers are discovering fascinating new details about Vitamin D.  What’s more, you can put many of their findings into use immediately to help ensure you maintain the optimum 50-60 ng/ml blood level of Vitamin D.

Here are five of the newest ways you can take action:

1. “D” stands for daily.

While we tend to think that Vitamin D is stored in the body, recent research suggests that one very important type of Vitamin D, cholecalciferol, has a very short half-life.  This means that to ensure the disease-protective benefits of Vitamin D it must be taken daily.  This also might explain why studies giving six months of Vitamin D in one large dose often show no beneficial effects.

2. You likely need more D than you are taking.

At the recent American College of Nutrition Conference, Vitamin D authority Dr. Robert Heaney reported that to reach his recommended target 40-60 ng/ml Vitamin D blood level the average person needs to supplement with 4,000-5,000 IU a day.  This is the same intake level I recommend for my clients at the Center for Better Bones and for you!

3. You can calculate your true supplemental need.

Scientists now know that for every 1,000 IU increase in your Vitamin D supplementation your blood level will increase by about 10 ng/ml.  So if you’re taking 2,000 IU a day and your Vitamin D blood test says you have a 30 ng/ml level, then adding 2,000 IU more will likely give you a 50 ng/ml level, and adding 3,000 IU more should give you a 60 ng/ml level. Test Your Vitamin D at Home!

4. Overweight and obese individuals need more Vitamin D.

We’ve known for a while that those of us with excessive body fat have lower Vitamin D levels.
At first it was thought that fat cells sequestered Vitamin D and were reluctant to release it.  But new research shows that obese individuals have higher Vitamin D binding proteins and thus less free, available Vitamin D.  Whatever the cause, if you are overweight, I suggest you have your Vitamin D level tested.

5.  Not absorbing your Vitamin D well?  Try this.

I also learned from Dr. Heaney’s recent lecture about the new unpublished finding that Vitamin D can be absorbed from the buccal lining tissues in the mouth.  If you can’t bring up your Vitamin D level with the supplements you are taking, try opening a capsule of dry Vitamin D and let it dissolve under your tongue.

Please let me know if these tips are helpful.  Be well and thrive!

Dr. Susan E. Brown

What’s the cause of your osteoporosis? Diagnostic tests and what they mean

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One of the basic principles of the Better Bones Program® is that all osteoporosis, all excessive bone loss, or all real increased risk of low-trauma fracture has a cause. To better understand any undetected causes of bone loss, it is important to obtain a medical work-up — that is, further tests — that can help find the causes of osteoporosis.

In addition to the standard DEXA bone density test, we suggest that our clients discuss the following tests with their doctor to see which ones are appropriate. Below are examples of tests that could be helpful and the basics of what the test results mean so that you can better discuss your personal situation with your doctor.  Join us for my online course that explains these medical tests for osteoporosis, which also includes a printable e-book you can bring to your doctor!

  • Vitamin D 25(OH)D blood test (available at-home)
  • Ionized calcium test *
  • Intact parathyroid hormone blood test (iPTH)*
  • 24-hour urine calcium excretion test *
  • Thyroid hormone function test (TSH)*
  • N-telopeptide crosslinks (NTx) urine marker of bone resorption test*
  • N-telopeptide crosslinks (NTx) serum marker of bone resorption test
  • C-Telopeptide (Collagen Cross-linked C-Telopeptide) CTx serum marker of bone resorption test*
  • P1NP test for bone formation*
  • Osteocalcin test*
  • Bone-specific alkaline phosphate (BAP) test*
  • Vertebral deformity assessment
  • Free cortisol test (blood or saliva)*
  • DHEA test (blood or saliva)*
  • C-reactive protein test (high sensitivity if possible)*
  • Homocysteine test (plasma or serum)*
  • Celiac disease and gluten sensitivity test*
  • Sex hormone tests*
  • Omega-3 Index (available at-home)

*These tests are available from a self-pay service that has partnered with the Better Bones Foundation. If you are unable to access these tests from your doctor, scroll to the end of this blog for more information.

Tests to help reveal what causes osteoporosis

Vitamin D 25(OH)D blood test

This test determines your blood level of vitamin D. The results tell you the amount of vitamin D supplementation needed to reach a therapeutic blood level of vitamin D, which is important for adequate calcium absorption and basic bone support.

What your results tell you: The reported “normal” range is very wide, often from 30 to 100 ng/mL. We now know that anything less than 32 ng/mL is likely to seriously limit calcium absorption and lead to bone loss. At the Center for Better Bones, we strive for a 50-70 ng/mL blood level of 25(OH)D.

Ionized calcium test

This is a simple blood test to measure the level of free calcium — that is, the metabolically active portion of calcium not bound to proteins in the blood. This test isn’t meant to assess the appropriateness of your calcium intake as much as it is meant as an indirect test of parathyroid functioning (see below). It can also indirectly tell us some things about vitamin D status.

What your results tell you: The body controls free calcium in the blood very tightly, with a normal laboratory range between 4.8 and 5.2 mg/dL (between 1.2 and 1.3 mmol/L) as reported by the Merck Index. When thinking of bone health, we look for high ionized calcium as a possible indirect indicator of excessive parathyroid hormone activity. A low ionized calcium level might be related to low albumin and low protein status.

 

Intact parathyroid hormone blood test (iPTH)

High parathyroid hormone levels are associated with excessive bone loss, as an overactive parathyroid gland draws calcium from bone. The medical reasons for this overactivity need to be addressed to halt the excessive bone loss. Also, a normal parathyroid reading in the face of vitamin D deficiency can indicate magnesium inadequacy.

What your results tell you: At the Center for Better Bones, we look for an intact parathyroid hormone level within the normal range established by the particular testing laboratory. Two common causes of an excessively high parathyroid hormone level are vitamin D deficiency (which is easily corrected with proper vitamin D3 supplementation and monitoring); and an overactive parathyroid, which is most often due to benign tumors on the parathyroid glands. Correction of this situation often requires surgery to remove the overactive glands.

Excessively high parathyroid hormone levels cause the body to release too much calcium from the bone contributing to bone loss, and more importantly, high blood calcium. A high parathyroid condition is best treated by an endocrinologist.

 

24-hour urine calcium excretion test

This test looks at how much calcium is being excreted in the urine. For this test, you collect all your urine over 24 hours in a large container for laboratory analysis to measure the amount of calcium in the total volume of urine. Excessive urinary calcium excretion is a common cause of bone loss and osteoporosis.

What your results tell you: The normal laboratory range for a person eating an average diet is around 100 to 250 mg of calcium lost in the urine each day. I consider a calcium loss of more than 250 mg to be a concern. In such cases, the first step is to stop all calcium supplements for 4 to 5 days and then retest the 24-hour urine calcium. If the urine calcium loss is still high, then steps should be taken to reduce this loss of calcium in the urine, as it can cause bone loss. Nutritional, lifestyle, and medical approaches can help.

 

Thyroid hormone function test (TSH)

TSH is a hormone produced in the pituitary gland that signals the thyroid to produce more of its hormones. If TSH is high, it usually means that the thyroid isn’t producing enough T3 and T4, so checking your TSH level is a simple way of screening for an underactive thyroid. Thyroid hormone levels that are too high or too low can contribute to osteoporosis, as can a dose of thyroid medication that is too high. To screen for overactive thyroid, or to make sure your dose of thyroid medications isn’t too high if you’re already being treated for hypothyroidism, you’ll need tests for free T3 and free T4.

What your results tell you: The common laboratory range for all adults is 0.35 to 5.50 and a more ideal level is 0.35 to 2.0.

 

 

Markers of bone resorption tests

Bone resorption (or breakdown) tests measure the amount of one specific bone protein in the urine or blood. As one loses bone this bone protein fragment shows up in the urine and blood in increased amounts. At the Center for Better Bones, we generally use the N-telopeptides crosslinks (NTx) urine test, but there are several others available. Other commonly used tests include the NTx serum test and the CTx serum test.

N-telopeptide crosslinks (NTx) urine marker of bone resorption test

What your results tell you: The test result “normal” range often listed on the test report is very broad. For example, test reports from our local lab list the premenopausal normal range for women as 17-94 nM BCE/mM creatinine and the postmenopausal range as 26-124 nM BCE/mM creatinine. The male range is 3-51. These ranges are far too wide to be useful.

Ideally, a woman would like to have an NTx level near that of the average premenopausal woman, which in the urine is around 35, but levels often soar into the 60s to 80s or higher in and around menopause. For adult men, the mean NTx is 27, which is a more ideal value than the higher numbers. Also, these markers can get very high in rare diseases such as Paget’s Disease and bone cancer. These situations are unusual and understood by a knowledgeable physician familiar with bone resorption testing.

We use the NTx urine test from Osteomark to judge the success of our bone building program. We look to bring the urine NTx level down to the 40s, which in most cases indicates that bone breakdown has normalized. There are some cases, however, where bone breakdown is very low, but bone build-up is even lower. This condition, known as “low turnover osteoporosis,” is detected when a person has a low NTx, but is still losing significant bone (5-6%) as seen on bone density testing.

N-telopeptide crosslinks (NTx) serum marker of bone resorption test results

What your results tell you: The NTx bone-breakdown marker can also be measured in the blood. The female range listed by the manufacturer is 6.2-19.0 nM BCE/L, with a mean of 12.6. The male range is often listed as 5.4-24.2 nM BCE/L, with a mean of 14.8. Again, this range is too wide to be useful for us at the Center for Better Bones. We look for a result of 12 or somewhat lower in women, and 14 or somewhat lower in men.

C-terminal telopeptide (CTx) of type-1 collagen serum marker of bone resorption test 

The CTx tests for the C-terminal telopeptide of type-1 collagen, which is a peptide fragment derived from the carboxy terminal end of the bone protein matrix. CTx is a blood test used to monitor the rate of bone breakdown and effectiveness of anti-resorptive natural or drug bone therapies. The serum CTx test should be done first thing in the morning before eating anything (in a fasting state). Twelve hours before this blood test, do not take multivitamins or dietary supplements containing biotin or vitamin B7 that are commonly found in hair, skin, and nail supplements and multivitamins.

Bone formation tests

Bone formation tests assess the rate of the development of new collagen and new bone. Three common tests are the P1NP test, the Osteocalcin test, and the BAP (bone-specific alkaline phosphate) test.

The P1NP test for bone formation

The P1NP is the preferred marker of bone formation test. P1NP (pro-collagen type-1 N-terminal propeptide) is formed by the bone-building cells and reflects the rate of collagen and bone formation. P1NP is the most sensitive marker of bone formation and particularly useful for monitoring bone formation therapies. It is recommended that this test be performed at baseline before starting a natural or pharmacological osteoporosis therapy and again 3 to 6 months later. Serum or plasma blood sample is acceptable. The test should be done first thing in the morning before eating anything (fasting state).

The osteocalcin test

Osteocalcin is the most important non-collagen protein in bone matrix. Osteocalcin is produced by the osteoblasts and is widely accepted as a marker of bone osteoblastic activity. Osteocalcin, incorporated into the bone matrix, is released into circulation from the matrix during bone resorption, hence is considered a marker of bone turnover rather than a specific marker of bone formation. The osteocalcin test is a blood test that should be done first thing in the morning in a fasting state. Twelve hours before this blood test, do not take multivitamins or dietary supplements containing biotin or vitamin B7 that are commonly found in hair, skin, and nail supplements and multivitamins.

The BAP test

Bone-specific alkaline phosphatase (BAP) is a glycoprotein found on the cell surfaces of the bone-building osteoblastic cells. As an indicator of osteoblastic activity, BAP is a marker of bone formation. Bone-specific alkaline phosphatase provides useful information on bone remodeling in osteoporosis and Paget’s disease. BAP is generally the first marker of bone formation to change with bone formation.

Vertebral deformity assessment

This is another x-ray test for bone that images each vertebral body of the spine and looks to see if there are deformities or fractures. The Vertebral Deformity Assessment can be done on newer bone density testing machines, with special software that takes a “lateral” view of the spine.

What your results tell you: The radiologist will give a full report of what he or she sees for each vertebral body, reporting any abnormalities, deformities, or fractures.

Free cortisol test (blood or saliva)

Cortisol is a corticosteroid hormone produced by the adrenal cortex, which is part of the adrenal glands. It is usually referred to as the “stress hormone” as it is involved in response to anxiety and stress. Abnormally high cortisol levels are damaging to bone and as such represent a major risk factor for osteoporosis and low-trauma fractures. This test can be done with blood or saliva.

What your results tell you: Cortisol is the “get up and go” hormone that should rise in the early morning and decline during the day. Thus, test results vary by what time of day the test was taken. Testing labs will give their normal range readings and the timing of the test should be taken into account when interpreting test results.

 

DHEA test (blood or saliva)

Dehydroepiandrosterone (DHEA) is a hormone produced by both the adrenal glands and the ovaries. DHEA helps to neutralize the effects of cortisol. DHEA helps to protect and increase bone density. Stress reduction activities like yoga and meditation can help maintain youthful DHEA level as we age. Low levels of DHEA are a risk factor for osteoporosis. This test also can be done with blood or saliva.

What your results tell you: In saliva testing, the results are often correlated with the results of the cortisol testing. It is also often measured as DHEA-S, that is, DHEA in its sulfated form. Again, each lab will offer its normal range depending on the test used.

 

C-reactive protein test (high sensitivity if possible)

C-reactive protein is a plasma protein that is held to be a marker of general inflammation within the body. It is a known risk factor for heart disease because heart disease is largely an inflammatory disorder. Osteoporosis is also inflammatory in nature and this test is helpful in detecting unwanted inflammation, which may contribute to bone health problems.

What your results tell you: Generally, in the C-reactive protein (or CRP) test, the lower the score the less inflammation and thus the better reading. I look for a high sensitivity CRP level less than 1.0mg/dL.

 

Homocysteine test (plasma or serum)

Homocysteine is a non-dietary amino acid, a product of the metabolism of a dietary amino acid, methionine. In the absence of adequate B vitamins, homocysteine can accumulate in the body. High levels of this substance damage collagen and represent powerful risk factors for both cardiovascular disease and for osteoporotic fractures.

What your results tell you: Normal levels of homocysteine in the blood range from 5 to 15 mM/L. At the Center for Better Bones we like to see a homocysteine level of 8 or below.

 

Celiac disease and gluten sensitivity test

Celiac disease, or even just sensitivity to gluten, can lead to inflammation of the gut. This inflammation is related to a complex inflammatory cascade which can increase bone loss. Also, those with celiac disease suffer from weak digestion and malabsorption of many nutrients including vitamins A, K, and D. These deficiencies in turn damage bone. If there is any suggestion of gluten sensitivity or celiac disease, appropriate testing should be considered

What your results tell you: There are varied tests used to help determine if one is suffering from gluten intolerance or the autoimmune condition known as celiac disease. Talk with your healthcare practitioner about what might be right for you.

 

 

Sex hormone test results

Post-Menopausal Females: Progesterone, Estrogen
Female sex hormones drop naturally at menopause among all women, so I don’t generally suggest testing of these hormones. Those interested in this type of hormone testing, or those taking hormone replacement medications, should be tested for hormone levels by their physician.

Pre-Menopausal Females (reproductive years hormone testing): Progesterone, Estrogen
For women from their teens to menopause, proper levels of sex hormones are very important to bone health. Low levels of either estrogen or progesterone can limit development of optimum peak bone mass. Irregular, or frequently missed, periods should be studied by a knowledgeable physician.

According to noted progesterone researcher, endocrinologist Dr. Jerilynn Prior, some 25% of young women in the US and Canada fail to develop optimum peak bone mass due to undetected ovulatory disturbances which result in low progesterone levels. Testing of estrogen and progesterone can be helpful in pre-menopausal women with a bone health concern.

Both blood and saliva testing are available for pre-menopause sex hormone testing. Each testing laboratory will have its range of normal sex hormone test results.

Sex Hormone Testing in Males: Testosterone and, at times, Estrogen
A common cause of osteoporosis in men is low testosterone; thus a medical work-up for osteoporosis in men almost always includes a test for testosterone. Interestingly enough, estrogen also plays a role in male bone health and at times the physicians will test for estrogen in men with osteoporosis.

Both blood and saliva testing are available for sex hormone tests in men. Each testing laboratory will have its range of normal sex hormone test results.

Omega-3 Index+ at-home test

This is a simple at-home blood test that measures the Omega-3 Index, Omega-6 to Omega-3 Ratios, Trans Fat Index and Complete Profile of 24 individual fatty acids. This test will explain what other fatty acid levels can (or can’t) tell you about your health, based on current research. Omega-3 fatty acids have been shown to benefit a wide variety of health conditions. They’ve also been associated with healthy aging in general. Unfortunately, most people don’t get enough of these important nutrients from their diet. Once you know your fatty acid blood levels, you can modify your diet and change these blood levels in as little as 3-4 months.

What your results tell you: As a part of an overall healthy lifestyle, an Omega-3 Index in the 8-12% range may help to maintain heart, brain, eye and joint health, and a Trans Fat Index of less than 1% may help to support heart and brain health. Further, studies show that an Omega-3 Index score of 6.8 or above is associated with a 35% lower risk of fatal heart attacks, a 34% lower risk of death from any cause, and a 4.7 year increase in additional life expectancy when compared with the average American Omega-3 Index score of 4.

 

Everyone deserves the full story on their health

It seems like today’s health care has become a knee-jerk reaction of “see a symptom, take a pill.” But we at the Center for Better Bones believe that everyone deserves better than that. Your bone loss is a symptom of something that’s just not right in your body — and rather than treating the symptom with medications (and living with the side effects involved, some of which are plain frightening!), I encourage everyone to dig deeper and find out the source of the problem.

New Offering from the Better Bones Foundation

Skip the doctor and order your tests online! So many times we hear from our clients and readers that their MDs are not willing to order the tests that they request. This is such a frequent occurrence that we wanted to find a way for women to obtain these necessary tests. In partnership with The Better Bones Foundation and Evexia Labs, we are now able to offer low-cost self-pay tests for those who want to know WHY they are losing bone.

The process is easy . . .

#1 Select the tests that you are interested in and submit your form below. Make sure you include your full address with city, state, and zip code. We will pass this information on to the lab on your behalf.

#2 Wait for an email from Evexia Lab with your username and password (also check your spam folder). Once you log in you will then be able to see the cost of the tests and can choose to self pay (no insurance accepted). After you pay Evexia will email you a requisition form for the lab.

#3 Print your requisition and take it to the nearest Labcorp facility. You can find a Labcorp close to you using this link: https://www.labcorp.com/labs-and-appointments. Self-pay testing is not available in NY, NJ, and RI.

#4.  In 2 to 4 weeks after getting the tests done, you will receive your lab results via an email notifying you that the results are ready. They can be viewed in your account or you can print them out and take them to your doctor for interpretation.

I am inquiring about the following tests: (Check all that apply)

Dr. Susan E. Brown

How much vitamin D should you take in the winter time?

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winter timeVitamin D: Winter check-up to keep levels optimal

How is it possible that six years have passed since I wrote about winter vitamin D levels while sitting poolside in the Dominican Republic, tropical drink in hand?  With time flying by, I understand when women tell me they’ve had their level checked “just a few months ago” but when they stop and think more carefully, it’s been several years.

This is one reason I remind you yearly about the importance of maintaining your vitamin D levels during the winter.

Have you had your vitamin D levels tested recently?

If not, do so now!  Vitamin D levels fluctuate throughout the year, generally rising in the summer months and dropping in the winter. Keep this in mind when you get your results. If you have marginal levels at the end of summer, for example, this is a warning sign that your levels may plummet in winter without proper supplementation.

How much vitamin D do you need?

While a blood level of 40 ng/mL is acceptable, a more optimal blood level of vitamin D is 50 to 60 ng/mL as measured by the 25(OH)D blood test.

Winter is a “vitamin D desert” up here in the northern latitudes, and unless you head south, below Atlanta to be exact, you will need to take vitamin D supplements to maintain an optimal blood level of vitamin D throughout the winter.

How much vitamin D to take varies greatly

On average we can use about 3,000 to 4,000 IU of vitamin D per day and taking this amount during winter months generally provides for at least a minimal protective level (which is around 32 ng/mL). However, many individuals need more than this, and a few who absorb vitamin D better might be able to get by on 1,000 or 2,000 IU per day.

How to test your vitamin D at home

Assuring that you and your family have adequate vitamin D levels is the simplest thing you can to do prevent disease and enhance health. Even winter colds and flu are much less common among those with adequate vitamin D on board! We have a  great service that will send you a kit so that you can test your Vitamin D at home.


References

Reference:

Lappe, Joan, M The role of Vitamin D in Human Health; A Paradigm Shift, Jr of Evidence-Based Complementary & Alternative Medicine 201, 16 (1) 58=72.

Bone fracture and Vitamin D
Dr. Susan E. Brown

Don’t be fooled: Vitamin D does prevent fracture

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I recently recorded a Facebook Live video critiquing a new study that suggested vitamin D does not prevent bone fracture. This study was published in The Lancet in October 2018 and was clearly flawed in many ways. For those of you who did not catch my video commentary on the shortcomings of this study, I summarize them here. Vitamin D prevents fracture.

Not all studies are created equal

I’ve been looking at the research on vitamin D for almost 30 years. It’s been clear for quite some time that you can reduce fracture risk with vitamin D if you obtain the therapeutic level of 32 ng/mL in your blood. So why would the new study claim that vitamin D doesn’t work to lower fracture risk?

To put it simply, the new study used a lot of vitamin D data that just wasn’t very good to start with. As a meta-analysis, it mined data from 80 studies on vitamin D from the past 20 to 30 years. But the problem is that most of these studies were flawed in the following ways:

They were mostly evaluating low doses of vitamin D (400–800 IU) that we know to be too low to affect fracture risk.

Many of them were too small and too short in duration to really assess the effectiveness of an intervention with vitamin D.

To be valuable, the study must document not only how much the participants took, but also whether they reached the therapeutic level. The vast majority of the studies didn’t report what blood level their participants reached—so none of them can say for sure that their participants had adequate vitamin D levels, particularly since few of them assessed the starting blood levels.

In those studies that did give higher doses of vitamin D, most of the time it was supplied in a single bolus of 100,000–300,000 units — which has been shown to be ineffective. To be most effective, the vitamin D dose should be given daily and it should always be given in the form of a natural vitamin D3 (cholecalciferol), not vitamin D2 (ergocalciferol).

The standard treatment for vitamin D deficiency uses 7,000 IU of vitamin D daily for 8 weeks, followed by testing of the new vitamin D level. Then the appropriate, long-term dose of vitamin D is determined. This is a dose that would provide at least a 32 ng/mL blood level of vitamin D, the minimum needed for health, with the goal of reaching an ideal range from 50–60 ng/mL.

Once vitamin D deficiency has been corrected, most individuals require 3000–4000 IU (or more) supplemental vitamin D daily to maintain an optimum blood level.

When you look at the data the study used, it’s pretty clear that this recent metanalysis is seriously flawed, and that the author’s conclusion that vitamin D is of no use in fracture prevention is both irresponsible and harmful.

So don’t be fooled — the value of vitamin D, established over many years of good research, is no different in 2018 than it was in 2008, when I first published my research review article on the subject.

Read More: How much vitamin D should you take in the winter time?

Test Your Vitamin D at Home

 

Click for References

Bolland MJ, Grey A, Avenell A. Effects of vitamin D supplementation on musculoskeletal health: a systematic review, meta-analysis, and trial sequential analysis. Lancet Diabetes Endocrinol. Published online October 04, 2018. DOI:https://doi.org/10.1016/S2213-8587(18)30265-1.

Brown SE. Vitamin D and fracture reduction: An evaluation of the existing research. Altern Med Rev. 2008;13(1): 21-33.

Vitamin D reduces breast cancer risk
Dr. Susan E. Brown

How much vitamin D do you need to reduce breast cancer risk?

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It has been recognized for over a decade that vitamin D has a protective effect against a variety of cancers, including breast cancer (Garland et al., 2006; Krishnan et al., 2010). But new research from our friends at GrassrootsHealth on vitamin D and breast cancer has me really excited. The group has found that maintaining a higher vitamin D level can reduce breast cancer risk by — are you ready for it? — a whopping 80 percent.

Higher vitamin D levels reduce breast cancer risk AND reduce bone loss

GrassrootsHealth recently combined two randomized clinical trials from Dr. Joan Lappe (Lappe et al., 2007; McDonnell et al, 2016) looking at women over four years. What they found was that was that those women who had vitamin D blood levels equal or greater then 60 ng/mL — the same levels helpful in preventing bone loss — had an 80% lower risk of breast cancer than women with concentrations less than 20 ng/mL (a very deficient level indeed).

Meanwhile, a similar study conducted recently showed that women with a vitamin D level above 38 ng/mL (about the level conventionally regarded as “adequate) had a 21% lower risk of breast cancer than women with levels at or below 24.6 (O’Brien et al., 2017).

You can’t help but notice the difference in risk reduction at 60 ng/mL versus 38 ng/mL is rather large. It reinforces what I’ve maintained all along — that current serum vitamin D recommendations are too low for women to get the best protective effects. But it also strongly supports the need for everyone to keep tabs on their vitamin D levels to ensure they don’t fall below the minimum level for bone health (and overall health).

Watch my interview with Carol Baggerly, the founder of GrassrootsHealth, to learn more about this groundbreaking research and Grassroots Heath’s new D-Action Cancer Prevention Society!

Test Your Vitamin D at Home!

References

Garland CF, Garland FC, Gorham ED, Lipkin M, Newmark H, Mohr SB, Holick MF. The role of vitamin D in cancer prevention. Am J Public Health. 2006 February; 96(2): 252–261.

Krishnan AV, Trump DL, Johnson CS, Feldman D. The role of vitamin D in cancer prevention and treatment. Endocrinol Metab Clin North Am. 2010 Jun;39(2):401–418.

Lappe JM, Travers-Gustafson D, Davies KM, Recker RR, Heaney RP. Vitamin D and calcium supplementation reduces cancer risk: results of a randomized trial. Am J Clin Nutr. 2007 Jun;85(6):1586–1691.

McDonnell SL, Baggerly C, French CB, Baggerly LL, Garland CF, Gorham ED, Lappe JM, Heaney RP. Serum 25-hydroxyvitamin D concentrations ≥40 ng/ml are associated with >65% lower cancer risk: pooled analysis of randomized trial and prospective cohort study. PLoS One. 2016; 11(4): e0152441.

O’Brien KM, Sandler DP, Taylor JA, Weinberg CR. Serum vitamin D and risk of breast cancer within five years. Environ Health Perspect. 2017; DOI:10.1289/EHP943.

Dr. Susan E. Brown

How much vitamin D should you take? That depends on you

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As we head into cooler weather, it’s the ideal time to get your vitamin D tested – whether you live in the north like I do or a warmer climate too.

You may not realize that even people who get adequate sunlight may become vitamin D deficient — with an impact on their bones.  That’s because vitamin D absorption and utilization differ, sometimes dramatically, from person to person.

Vitamin D needs vary greatly

Here are just a few interesting examples I’ve seen:

  • One woman in Connecticut had a vitamin D of level of 33 ng/mL in March — barely above the acceptable lower limit — despite taking 6600 IU of vitamin D during winter.  She increased her intake to 8600 IU for several months to reach the ideal 50 ng/mL level.
  • Another northeastern woman tested in August — when you’d expect her levels to be highest — was only 35 ng/mL despite taking 2000 IU of vitamin D daily year-round. She needed to add 2000 IU more to reach an optimal level. Contrast this to another client living in Denver, who had 53 ng/mL vitamin D in January when she was only taking 1000 IU daily.
  • And then there’s my own case — living in central New York, I was using 2800 units of vitamin D during the summer and getting lots of sunshine from my outdoor activities, but I still tested at 35 ng/mL in October.  If I had not raised my wintertime vitamin D intake substantially to 5,800 IU/day, I would’ve had a very inadequate level of vitamin D during the winter.

On average, vitamin D levels are expected to increase 10 ng/mL for every additional 1000 IU of vitamin D — but as you can see, the average doesn’t mean much in real-world situations! That’s why it’s crucial to get vitamin D testing to identify where you are starting — and retest a few weeks later to see if the amount you use is having an impact.

How much Vitamin D should I take?

How much Vitamin D should I take?

References:

Boroń, D., Kamiński, A., Kotrych, D. et al. Polymorphisms of vitamin D3 receptor and its relation to mineral bone density in perimenopausal women. Osteoporos Int (2015) 26: 1045. doi:10.1007/s00198-014-2947-3

Hollis, B. W., Wagner, C. L., Howard, C. R., Ebeling, M., Shary, J. R., Smith, P. G., … & Hulsey, T. C. (2015). Maternal versus infant vitamin D supplementation during lactation: a randomized controlled trial. Pediatrics,136(4), 625-634.

Drincic, Andjela T., et al. “Volumetric dilution, rather than sequestration best explains the low vitamin D status of obesity.” Obesity 20.7 (2012): 1444-1448.
Mayo Clinic. Vitamin D toxicity rare in people who take supplements, researchers report. ScienceDaily, 30 April 2015.

* Information presented here is not intended to cure, diagnose, prevent or treat any health concerns or condition, nor is it to serve as a substitute professional medical care.

what is the most important thing for bone health
Dr. Susan E. Brown

1 minute with Dr. Brown: What is the most important thing for bone health?

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Got a minute? Every week I receive dozens of questions from women like you with concerns about their bone health. In my new series, “1 Minute with Dr. Brown,” I will try to answer your most pressing questions. If you have a question, send it in to us at center@betterbones.com
 

Question: What is the single most important thing I can do to take care of my bone health?

Flu connecting to low vitamin D
Dr. Susan E. Brown

Low vitamin D means more flu

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Did you ever wonder why you end up suffering from the flu nearly every winter? You may not be getting enough vitamin D.

The darker winter months are when our sun-dependent vitamin D levels are at their lowest.

Among its many other actions, vitamin D stimulates and supports immune function. And in temperate latitudes, researchers find that pandemic influenzas generally show clear seasonality.

In other words: More cold dark days, more flu.

Growing research connects vitamin D and influenza

  • Women given 800 IU of vitamin D daily were 3 times less likely to report cold and flu symptoms than those not given vitamin D. This study was a randomized controlled trial looking at bone loss in postmenopausal African American women.
  • A study with intake of 2,000 IU of vitamin D daily for one year efficiently protected women against typical winter colds and influenza.
  • A trial comparing vitamin D supplements with placebos in schoolchildren found that only 1,200 IU per day of vitamin D during winter and early spring reduced the incidence of seasonal influenza by a factor of two.

Protect yourself from winter flu related to low vitamin D

  • Maintain a 50 to 60 ng/ml vitamin D level all year round to get the fullest possible benefits from vitamin D.
  • Get your vitamin D tested now to prepare for the winter. To get your level to the optimal 50 to 60 ng/ml some may require the intake of 4,000 to 5,000 IU daily of vitamin D or even more. For others lesser doses are sufficient. Some people absorb vitamin D better than others, some seem to have a higher need and others have higher reserves from the summer. Test Your Vitamin D at Home!
  • Determine how much extra D you need. As a rule of thumb, for every 1,000 IU increase in vitamin D your vitamin D blood level will increase by 10 ng/ml. So if you measure your level in December and it is 30 ng/ml, you would add 2,000 IU more vitamin D to your daily supplement program to get to a 50 ng/ml.

Here’s to a happy, healthy winter season!

 

Reference:

Cauley JA, Chlebowski RT, Wactawski-Wende J, et al. Calcium plus vitamin D supplementation and health outcomes 5 years after active intervention ended: the Women’s Health Initiative. J Women’s Health (Larchmt). 2013;22:915-929.

how can we tell who will fracture
Dr. Susan E. Brown

How can we tell who will fracture? Beyond bone mineral density to the new world of fracture risk assessment

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More than twenty-five years ago, I first consulted with several of the individuals who developed the bone density testing machines. The hope was clear — if we could measure bone density we would be able to predict who will experience an osteoporotic fracture. The concept was quite simplistic; it assumed that the most important fracture-determining factor was low bone density. Over the last decades, bone density testing has become widespread; yet the hope for a simple, straight predictor of fracture has faded.

Today, nearly three decades later, we realize that you cannot predict who will fracture from measurements of bone density alone. In fact, recent large studies show that a large percentage of people who do fracture do not have osteoporotic bone density, but actually have only osteopenia or even normal bone density. Furthermore, many people with an osteoporotic bone density never fracture.

Most fractures occur in those who do not have osteoporotic bone density

As early as the mid 1980’s, thoughtful osteoporosis researchers noted that hip fractures could not simply be attributed to low bone mass. As Steven Cummings wrote in 1985, “Patients with hip fractures do not appear to be distinctly more osteoporotic than persons of similar age. Therefore, factors besides bone mass, such as a tendency to fall, may be important determinants of which elderly persons will have fractures; thus, measurements of bone mass might not be a reliable way to identify those at greatest risk of hip fracture.”

Over the last two decades numerous clinical trials have borne out the truth of Dr. Cummings’s early observation. For example, the US Study of Osteoporotic Fractures (SOF) looked at 8,065 women 65 and older, following them for hip fracture incidence over a five year period. Within these five years, 243 hip fractures occurred, 54% of which were in women who did not have an osteoporotic bone density at the start of follow-up. Further reports from this same Study of Osteoporotic Fractures database found that only 10% to 44% of osteoporotic fractures occurred in those with an osteoporotic bone density. As these authors summarize, “Finding effective prevention strategies for fractures in older women will require additional interventions beside [sic] preventions for bone loss, such as prevention of falls and other fracture risk factors.”

The same has been found true in other large studies of osteoporotic fractures, such as the 149,524-women US National Osteoporosis Risk Assessment (NORA) study. Over a one-year period in this large group of women (mean age 64.5), 2,259 new fractures were self-reported, including 393 hip fractures. Of those who fractured, a full 82% had a non-osteoporotic bone density (greater than -2.5 SD T-score) and a full 67% had a T-score greater than -2.0. In total, 6.4% of all women had an osteoporotic bone density. Although fracture rates were highest in this “osteoporotic bone mineral density” group, these women experienced only 18% of all osteoporotic fractures and 26% of all hip fractures.

All in all, many factors are as important, or even more important, indicators of fracture risk than is bone mineral density. For example, fracture after age 40, parental history of hip fracture, low body weight, high rate of bone resorption, deficiencies of vitamins D and K, use of steroid medications, and several other factors are stronger fracture predictors than bone mineral density.

The new fracture assessment tools: multiple risk factor assessment with and without bone density measurements

So a new question arises. How can we tell who will experience an osteoporotic fracture? We now realize that the answer lies not in any single factor like bone density, but rather in assessment of multiple risk factors. What we are already beginning to see is a series of assessment tools which allow individuals and health practitioners to sort out who is likely to fracture according to a series of important variables, not just according to bone mineral density. Further we see that the operative risk factors may vary somewhat by populations studied.

New fracture risk assessment tools: post-menopausal women

One of the best known early fracture assessment tools is the “Fracture Index.” This index was developed using data from the large US Study of Osteoporotic Fractures (SOF). In the SOF, a total of 7,782 US women aged 65 and older were studied over five years.

In the SOF, measurements over time were made of bone density and other variables which were thought to reflect upon bone strength. These variables were compared with actual fracture incidence allowing for the development of a fracture risk screening and assessment tool. With this large data base, researchers identified a seven-variable model which allowed them to make a fairly accurate prediction of the five-year risk of suffering an osteoporotic fracture for any individual.

So what were the factors and variables that seem to determine if one will facture or not? According to the SOF research, the seven most important factors were found to be:

  1. Age
  2. Bone mineral density T-score
  3. Fracture after age 50
  4. Maternal hip fracture after age 50
  5. Weight less than or equal to 125 pounds (57 kg)
  6. Smoking status
  7. Using one’s arms to stand up from chair

According to researchers, this simple seven-factor assessment was shown to be predictive of hip fracture, as well as other non-vertebral fractures. It is also interesting that this risk assessment was shown to be predictive of fracture likelihood with or without incorporating one’s bone density into the assessment. Subjects with the greatest number of risk factors, even without accounting for bone mineral density, had a 14-fold increase risk of fracture as compared to those with the lowest number of risk factors.

In a similar fashion, the large Women’s Health Initiative (WHI) study used its data to develop another five-year fracture risk assessment tool. This 7.6-year trial studied 93,676 women of various ethnic backgrounds, ages 50 to 79 at entry. They found that each year some 1.6% of all women suffered hip fractures. From their analysis they developed a risk assessment tool identifying 11 key risk factors (not including bone density) to predict who would fracture a hip over the next five years. This model, based on these key risk factors, was found to be of similar predictive value as the more expensive bone density tests.

The 11 key risk factors uncovered from the Women’s Health Initiative (WHI) were:

  1. Age
  2. Self-reported health
  3. Weight
  4. Height
  5. Race/ethnicity
  6. Self-reported physical activity
  7. History of fracture after age 54
  8. Parental hip fracture
  9. Current smoking
  10. Current corticosteroid use
  11. Treated diabetes

New fracture risk assessment tools: identifying osteopenic women at risk for fracture

More than half of all low-trauma osteoporotic fractures among women occur in those who do not have an “osteoporotic” bone density; rather, they occur in women with an osteopenic bone density or, even in some cases, a normal bone density. Obviously in these cases we must look beyond bone density in our attempt to assess who is likely to fracture.

Data from the large NORA study attempted to identify those osteopenic women at short-term risk for fracture. In the NORA study, 57,421 post-menopausal women ages 50 to 99 were identified as having osteopenia. That means they had a bone mineral density from -1.0 to -2.5 SD T-score. In this study, bone density was measured at the heel, forearm, or hand. These women had bone density lower than that of young women, but they did not have an “osteoporotic” bone density (-2.5 SD T-score or more). Of the osteopenic women studied, 130 reported new fractures within one year of the bone density measurement.

Four risk factors were found to be the most important for identifying those at highest risk of short-term fracture. These were:

  1. Previous fracture
  2. Bone density T-score of -1.8 or less
  3. Self-rated poor health status
  4. Poor mobility

Women with a previous fracture had a one-year fracture risk of 4.1%, followed by women with T-scores of -1.8 or less or with poor health status. Nearly 2% of the women with poor mobility came to fracture within the year. About 1% of the osteopenic women not identified as being at risk experienced a fracture within the year. This 1% per year fracture incidence is the same as that found among women with normal bone density.

Other interesting findings of this study showed that being younger did not seem to protect the early post-menopausal women.

  • Younger women, aged 50 to 59, who shared a similar risk profile to that of women aged 60 to 69 had a similar 1-year risk of fracture (1.6% as compared to 1.7%).
  • Younger women aged 50 to 59 who were identified to be at increased risk had an absolute fracture risk of 2.6%. This was similar to that of the entire at-risk population of all ages (50 to 99 yrs).
  • Younger women aged 50 to 59 with a history of previous fracture after age 45 had a 4.5% fracture risk. This is similar to the risk for women with an osteoporotic bone density.

New fracture risk assessment tools: the World Health Organization (WHO) master assessment

Over the years the World Health Association (WHO) has analyzed various large population-based studies to develop a fracture risk assessment tool based on clinical factors. This assessment tool is designed to be useful both with and without bone density measurements and indeed, this is important, as much of the world does not have access to bone density measurements. Completed in March 2008, the WHO Fracture Risk Assessment Tool identifies 10 factors found to increase fracture risk independent of bone mineral density. (See http://www.shef.ac.uk/FRAX.) The independent risk factors are:

  • Age
  • Sex
  • Weight and height
  • Previous fractures
  • Parental hip fracture history
  • Smoking status
  • Glucocorticoid use
  • Rheumatoid arthritis
  • Secondary disorders linked to osteoporosis, such as type 1 diabetes
  • Drinking three or more alcoholic beverages per day

WHO fracture risk assessment

At age 40, a US Caucasian woman weighing 135 lbs at 5’8” with none of the WHO risk factors has a 2.3% risk of experiencing a major osteoporotic fracture within ten years. The same woman with five of the WHO risk factors has a 15% risk of experiencing a major osteoporotic fracture. At age 65, the same woman with none of the WHO risk factors has a 14% chance of experiencing a major osteoporotic fracture within ten years. This same woman at 65, with five of the WHO risk factors, has a 55% risk of experiencing a major osteoporotic fracture. At age 80, the woman with none of the WHO risk factors has a 28% chance of experiencing a major osteoporotic fracture within ten years. The same 80-year old woman with five of the WHO risk factors has a 71% risk of experiencing a major osteoporotic fracture.

Age
Weight & Height
Number of Additional “WHO” Risk Factors
Risk % for a Major Osteoporotic Fracture within 10 Years
40135 lbs. / 5’8
0
2.3%
40135 lbs. / 5’8
5
15%
65135 lbs. / 5’8
0
14%
65135 lbs. / 5’8
5
55%
80135 lbs. / 5’8
0
28%
80135 lbs. / 5’8
5
71%

You may want to take this risk assessment yourself. It can be done with or without a bone density measurement. The link is: http://www.shef.ac.uk/FRAX

Does fracture risk vary by ethnicity?

This is a fascinating question which we have just begun to ask. I am confident the answer will be yes, risk does vary by ethnicity. Even with the little bit of existing research we have on the topic, we know that bone mineral density in Black women does not carry with it the same risk of fracture as it does among Caucasian women. Black women have about 30% fewer fractures at any given bone mineral density than Caucasian women. We also know that overall, Asians experience far fewer fractures than do Caucasians, yet their bone density is significantly lower.

The future of fracture risk assessment

As director of the Better Bones Foundation, I know that multi-variable risk assessments are indeed the tools of the future. I am not sure, however, whether the 7 variable model set forth by the US Study of Osteoporotic Fractures, or the 11-factor model from the Women’s Health Initiative, or even the new WHO assessment will end up being the best risk assessment tool. Yet there are a few things we do know for sure. One is that bone strength is determined by many factors, not just bone density; and many factors contribute to bone weakness. Further, every day we come to understand more about important new fracture risk factors which are yet to be incorporated in these risk assessment tools.

New risk factors: what the future might hold

As new questions are asked and new research unfolds, we are confident that many more new risk factors will become more important than bone mineral density. The new important fracture risk factors I would like to review are:

  • High rates of bone protein matrix breakdown (high bone resorption rates)
  • Low serum levels of vitamin D
  • Low serum levels of vitamin K
  • Use of various additional medications

New risk factor: high rates of bone protein matrix breakdown

Bone can be visualized as a living protein sponge matrix upon which mineral crystals are imbedded. As bone is lost, this living protein matrix breaks down and is excreted in the urine. The more bone protein fragments found in the urine, the higher the rate of bone breakdown. This is known as the rate of bone resorption. High bone resorption generally indicates a high rate of bone loss. Urine tests which measure bone resorption include the NTx, CTx, and the free deoxypryidinoline urine Dpd tests. These urine indices of skeletal turnover are as useful, or nearly as useful, as bone density in predicting fractures. They are fracture risks independent of bone density. Further, the combination of high bone resorption and low bone density is especially predictive of increased fracture risk.

New risk factor: low serum levels of vitamin D

Only recently have we begun to understand the overwhelming importance of vitamin D in fracture prevention. While it is beyond the scope of this article, suffice it to report that the vast majority of hip fractures occur in vitamin D deficient people. Among those who experience an osteoporotic fracture, vitamin D deficiency is the rule, not the exception. For example, a Minnesota hospital study of 82 minimal-trauma fracture patients ages 52-97 found that 97% of the fractures were hip fractures and that all but two of the patients had deficient vitamin D status (less than 30 ng/mL). In a large British study, vitamin D deficiency was found in 95% of hip fracture patients. Further supporting this, 78% of hip fracture patients in a Boston study were vitamin D deficient. Findings such as these have led some researchers to ask if vitamin D level is not the best predictor of fracture risk.

New risk factor: low serum levels of vitamin K

While only limited research attention has been given to the vitamin K-fracture link, the powerful role of this nutrient in fracture prevention is obvious. European researchers have shown that the marker of vitamin K insufficiency (undercarboxylated osteocalcin) strongly predicts fracture. Those with the greatest signs of vitamin K insufficiency were found to have twice the risk of hip fracture, independent of bone density. Further, a combination of low vitamin K status and low bone density increased one’s risk of hip fracture by more than five-and-a-half-fold.

New risk factor: use of various additional medications

It has long been known that the use of corticosteroids like prednisone greatly increase one’s risk of fracture. Now researchers are beginning to uncover links between other medications and fracture risk. For example, a recent British study found that those using higher doses of acid blockers (proton pump inhibitors) for more than a year had a 250% increased risk of hip fracture than non-users. Anti-depressants are another example of medications that increase fracture risk. Recently the large CAMOS 5-year Canadian osteoporosis study found that use of anti-depressants known as serotonin reuptake inhibitors (SSRI’s) was associated with increased fracture risk. Individuals using these medications, such as Prozac, Zoloft, and Paxel, for five years or more, had twice the risk of osteoporotic fracture than those not using these drugs. Further, hip bone density was 4% lower and spinal bone density 2.4% lower in those who used anti-depressants as compared to non-users.

In conclusion

While it is interesting to look at large studies and try to sort out the characteristics of folks at high risk for fracture, it is important to keep in mind that we can only predict relative fracture risk. We cannot foretell who will fracture. As research continues, more fracture risk factors will be uncovered and a relative weighting of their importance outlined. In the meantime, the known cluster of bone-weakening factors now include advancing age, low body weight, inadequacies of vitamins D and K, parental hip fracture, personal low-trauma fracture, selected medications, fragility and poor mobility, poor general health, high bone resorption, and low bone density.