Supplements and Health

American Omega-3 Deficiency

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Is There an American Omega-3 Deficiency?

Author: Dr. Stephen Chaney

omega 3 deficiencyOmega-3s have been controversial in recent years.  However, virtually everyone agrees that omega-3 intake in North American is low. But, would you believe that the United States and Canada are dead last with respect to omega-3 status – that we are among the countries with the lowest omega-3 status in the world? Is there an American omega-3 deficiency?  That is what a recent study suggests!

Omega-3 Deficiency in Americans

Previous studies have suggested that the American and Canadian diets were deficient in long chain omega-3s like EPA and DHA, but those studies were based on 24-hour diet recalls or food frequency surveys which might underrepresent the true amount of omega-3s in the diet. Therefore, a group of investigators from the United States and Canada decided to look at blood levels of EPA and DHA.

This study (Stark et al, Progress In Lipid Research, 63: 132-152, 2016) was a meta-analysis of 298 studies that recorded blood levels of EPA and DHA. These studies were from 36 counties and distinct regions around the world. They converted all of the measurements to a common unit expressed as percent by weight of EPA + DHA relative to the total weight of fatty acids in the blood.

American omega-3 deficiencyThey combined all studies from a given country or region to give an average value of percent EPA + DHA and then divided the countries and regions into four groupings based on the average weight percentage of EPA + DHA in the blood. If all that seems confusing, the figure on the right (taken from Stark et al, Progress In Lipid Research, 63: 132-152, 2016) should clear things up.

  • Red = very low (< 4%) EPA + DHA levels
  • Orange = low (4-6%) EPA + DHA levels
  • Yellow = moderate (6-8%) EPA + DHA levels
  • Green = adequate (>8%) EPA + DHA levels
  • Grey = no valid measurements in those countries

It is clear from this study that most Americans and most Canadians don’t do a very good job of incorporating omega-3 fatty acids into their diet, as several previous dietary surveys have suggested.  This could contribute to omega-3 deficiency.

Is The United States Dead Last In Omega-3 Status?

The global map of EPA + DHA blood levels certainly suggests that the United States is among a handful of countries with the very lowest omega-3 status. There are a few caveats, however.

  • As the large areas of grey indicate, there are a number of countries with no valid omega-3 blood measurements. The United States might have lots of company in the very low omega-3 status category.
  • There are some very large countries like Russia which have relatively few omega-3 blood measurements, and those measurements are only from a few regions of the country. The average omega-3 status for the entire country might be lower than indicated in this map.

On the other hand, there are lots of omega-3 blood measurements from countries like Japan, so it is clear that there are countries with much better omega-3 status than the United States.

What Does This Study Mean To You?

The important questions are, of course:Does it matter? What do these blood levels of EPA + DHA actually mean? Is < 4% EPA + DHA low enough to matter? What are the health consequences of low omega-3 status?  If you have an omega-3 deficiency, what are the risks?

Let’s start with the first question: How do we translate a blood level of EPA + DHA into how much we should be getting in our diet? While there is no established Dietary Reference Intake for EPA + DHA, several expert panels and international organizations have made recommendations for EPA + DHA intake. Those recommendations generally range from 250 mg/day to 500 mg/day for general health and 500 mg/day to 1,000 mg/day for heart health. Unfortunately, most people in the United States and Canada consume less than 200 mg/day of omega-3 fatty acids, and most of those are short chain omega-3s that are inefficiently converted to the long chain EPA and DHA.

More importantly, a recent study (Patterson et al, Nutrition Research, 35: 1040-1051, 2015) has examined how much additional EPA + DHA must be consumed by someone eating a typical North American diet to significantly improve their omega-3 status. It showed that:

  • 200 mg/day of EPA + DHA is required to improve omega-3 status from very low to low.
  • 500 mg/day of EPA + DHA is required to improve omega-3 status from very low to moderate.
  • 1250 mg/day of EPA + DHA is required to improve omega-3 status from very low to adequate.

omega-3 for heart healthIt is no surprise that these numbers correlate so well. My recommendation would be to consume at least 500 mg/day of EPA + DHA for general health and at least 1,000 mg/day for heart health.

Now let’s look at the last question: What are the health consequences of low omega-3 status? There are multiple health benefits associated with optimal omega-3 status, but the best evidence is for the beneficial effects of omega-3s on fetal and infant neurodevelopment and heart health. For example:

  • In case you have been confused by recent studies suggesting that omega-3s have no effect on heart health you should know that most of those studies were looking at the effect of EPA + DHA in patients who were already taking 3 or 4 heart medications. The studies actually concluded omega-3s provided no additional benefits in people already taking multiple heart medications. That is a totally different question.

Where Should You Get Your Omega-3s?

fish oil supplementsNow that you know how important the long chain omega-3s, EPA and DHA, are for your health, and you know that most of us have a very poor omega-3 status and therefore have an omega-3 deficiency , your next questions are likely to be: “What’s the best way to improve my omega-3 status?” and “Where can I find EPA and DHA in my diet?” The answer is complicated.

  • Cold water, oily fish like salmon are a great source of EPA and DHA. Unfortunately, our oceans are increasingly polluted and some of those pollutants are concentrated even more in farm raised fish. A few years ago a group of experts published a report in which they analyzed PCB levels in both wild caught and farm-raised fish from locations all around the world (Hites et al, Science 303: 226-229, 2004) . Based on PCB levels alone they recommended that some wild caught salmon be consumed no more than once a month and some farm raised salmon be consumed no more than once every other month!

Unfortunately, when you buy salmon in the grocery store or your favorite restaurant, you can ask whether the salmon is wild or farm-raised, but you have no idea where the salmon came from. You have no idea how safe it is to eat. I love salmon and still eat it on occasion, but not nearly as frequently as I used to.

As an aside, the buzzword nowadays is sustainability. I support sustainability. However, the easiest way to assure that fish are sustainable is to raise them in fish farms. When a waiter tells me how sustainable the “catch of the day” is, I ask them how polluted it is. If they can’t answer, I don’t buy it. My health is more important to me than sustainability.

  • Nuts, seeds, and canola oil are good sources of ALA, a short chain omega-3 fatty acid. These food sources are less likely to be contaminated, but the efficiency of conversion of ALA to EPA and DHA is only around 5-10%. In other words, you need to eat a lot of ALA-rich foods to enjoy the health benefits associated with EPA and DHA.
  • That leaves fish oil supplements, but you need to remember that the EPA + DHA supplements you purchase in the health food store come from polluted fish. Unfortunately, many manufacturers have inadequate purification and quality control standards. In other words, neither you nor they know whether their omega-3 products are pure. You need to make sure that the omega-3 supplement you purchase is made by a manufacturer with stringent quality control standards.

 

The Bottom Line

 

  • A recent study has shown that most Americans are deficient in long chain omega-3s like EPA and DHA. In fact, the mainland United States and Canada were tied with half a dozen other countries for the lowest omega-3 status in the world.  Omega-3 deficiency in Americans seems to be the worst.
  • That is unfortunate because recent studies have shown that optimal blood levels of EPA and DHA are associated with a number of health benefits, especially fetal and infant neurodevelopment and heart health.
  • Other studies suggest that most Americans should consume an extra 500 mg/day of EPA + DHA for general health and at least 1,000 mg/day for heart health.
  • Unfortunately, it is not easy get those levels of EPA and DHA from our diet:
  • Oily, cold water fish are a great source of EPA and DHA, but our oceans are increasingly polluted and experts recommend that some fish that are the best sources of EPA and DHA be consumed no more than once a month. The situation is even worse for farm-raised fish.
  • Of course, nowadays the buzzword for fish is sustainability, but sustainability does not guarantee purity. Sustainable fish can be just as polluted as the worst of the farm raised fish.
  • seeds and canola oil are great sources for ALA, a short chain omega-3 fatty acid. This source of omega-3s is less likely to be contaminated, but the efficiency of conversion of ALA to EPA and DHA in our bodies is only around 5-10%.
  • Fish oil supplements can be a convenient source of the EPA and DHA you need, but the fish oil often comes from polluted fish and many manufacturers have inadequate purification methods and quality control standards. If you choose fish oil supplements as your source of omega-3s, be sure to choose a manufacturer with stringent quality control standards. Otherwise, neither you nor the manufacturer will know whether their omega-3 supplement is pure.

 

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure or prevent any disease.

Calcium and Breast Cancer Prevention

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Author: Dr. Stephen Chaney

 

calcium and breast cancerIs there a connection between calcium and breast cancer prevention?  There has been lots of confusion about calcium supplements lately. Just a few years ago most health professionals were recommending calcium supplementation for women to prevent osteoporosis. Now that recommendation has become controversial. That’s because some studies have suggested that increasing calcium intake doesn’t actually prevent osteoporosis. Other studies have suggested that calcium supplementation may actually cause heart disease.

As if all this wasn’t confusing enough, the latest headlines are claiming that increased calcium intake will reduce breast cancer risk. What are we to believe about the value of calcium for our health? Should we take that calcium supplement we threw away out of the trash can and start using it again?

I have previously evaluated the studies behind the previous headlines and debunked the headlines. For example, I reported that previous studies suggesting that calcium supplementation might increase heart attack risk were followed by a much larger, better designed study showing that, if anything, calcium supplementation actually decreases heart attack risk in Do Calcium Supplements Increase Heart Attack Risk?. I also reported that the study claiming calcium supplements did not prevent osteoporosis was fatally flawed in Do Calcium Supplements Prevent Bone Fractures?.

Now it is time to evaluate the study behind the latest calcium headline. Is this headline myth or is it true?  What is the connection between calcium and breast cancer.

 

Calcium and Breast Cancer Risk Reduction

calcium reduces breast cancer riskThis study (Hidayat et al, British Journal of Nutrition, 116: 158-166, 2016) was a meta-analysis of 11 previous clinical studies published between 2002 and 2013 with a total of 872,895 women subjects which measured calcium intake and breast cancer. Follow up ranged from 7 to 25 years in these studies, during which time 26,606 of the women developed breast cancer.

Dietary plus supplemental calcium intake was determined at the beginning of each study using either a 24-hour diet recall or a food frequency questionnaire. Calcium intakes ranged from 203 mg/day to 1,750 mg/day.

In short this was a very large and well done study. Because of the large number of subjects and the large number of cancer cases, this study had the sensitivity to detect even small effects of calcium on breast cancer risk – something that was not possible in previous studies. In addition, the investigators were able to conduct a dose-response evaluation of the effect of calcium and breast cancer risk reduction. This was also had not been possible in previous studies.

When the women with the highest calcium intakes were compared to the women with the lowest calcium intakes:

  • Calcium reduced breast cancer risk by 8%.
  • The effect was much larger for premenopausal women than postmenopausal women:
  • Calcium reduced breast cancer risk by 25% in premenopausal women.
  • Calcium reduced breast cancer risk by 6% in postmenopausal women.
  • The dose response effect was fairly linear over the entire dose range with a 2% decreased risk of breast cancer for every 300 mg/day increase in calcium intake.

 

What Does This Study Mean For You?

As I said in the beginning, when you read the headlines proclaiming that increasing your calcium intake could decrease your breast cancer risk, you probably had two questions:

Is it true?  The answer appears to be yes. This was a very large, very well done study and it showed there is a connection between calcium and breast cancer risk reduction. It was capable of detecting even small effects of calcium on breast cancer risk – something that previous studies simply could not do.

Does it matter?  Here the answer is more complicated. If you’re a postmenopausal woman, increased calcium intake only decreases your risk of breast cancer by 6%.  If you are a premenopausal woman, increased calcium intake decreases your risk of breast cancer by a more robust 25%. However, in both cases you should think of calcium as only one component of a holistic approach to reducing breast cancer risk – something I’ll discuss in more detail below.

Now that you know the answer to those two questions you probably have a third question:

How much calcium do I need?   That’s pretty simple. The calcium DV for adults is 1,000 mg/day, increasing to 1,200 mg/day for women over 50.

How Can You Reduce Breast Cancer Risk?

In a previous article Preventing Osteoporosis,  I reported that while calcium supplementation alone had only a very modest effect on reducing osteoporosis risk, it played an important role as part of a holistic bone-healthy lifestyle. The role of calcium in reducing breast cancer risk is no different.

Most experts estimate that between 30 and 60% of breast cancer cases could be prevented by diet and lifestyle changes. In addition to calcium, both the Mayo Clinic  and the American Cancer Society make the following recommendations for reducing breast cancer risk:

  • calcium supplementsLimit or avoid hormone therapy. This is the single most important step you can take to reduce breast cancer risk.
  • Eat a plant-based diet with plenty of fresh fruits and vegetables, whole grains, legumes and nuts. Use fats in moderation and choose healthy fats such as olive oil and omega-3 fats. Limit the amounts of red meat and processed meats.
  • Control your weight.
  • Be physically active.
  • Don’t smoke
  • Limit alcohol intake.
  • Avoid exposure to radiation and environmental pollution.
  • Breast feed.

Where Should You Get Your Calcium?

Many experts recommend that you get your calcium only from food. Is that the best advice?  I always like to start with food as the source of essential nutrients, but in the case of calcium that usually isn’t sufficient. Here are some facts to ponder:

  • Plain, nonfat yoghurt is the calcium champion, with an 8 ounce serving supplying 42% of the DV (the calcium DV = 1,000 mg/day). However, most yoghurt cups in the market these days are 4 ounces or less.
  • Milk and a few cheeses supply around 30% of the DV. However, many people can’t or don’t consume the 3 or more servings needed to reach the DV.
  • Green leafy vegetables are often mentioned as another good food source. However, a serving of them only provides around 10% of the DV, and many leafy greens contain oxalates which decrease calcium absorption.
  • Beyond that,  most food sources of calcium supply only 1-8% of the DV for calcium. If you don’t drink lots of milk, you need to be a dietitian with an advanced degree to figure out how to get enough calcium from foods alone.
  • If that isn’t bad enough, many foods contain substances that interfere with calcium absorption. In addition to the oxalates in leafy greens, these substances include phytates from whole grains, phosphate from sodas, and saturated fat from red meats.

 

Experts often also recommend getting calcium from calcium fortified foods such as calcium fortified orange juice. That can help you reach the recommended calcium intake, but in my opinion calcium-fortified foods are likely to be more expensive and no better than regular foods plus a calcium supplement.

I recommend getting as much calcium as possible from food and adding a calcium supplement for the rest. Here are my tips on calcium supplementation:

  • If you do use a calcium supplement, make sure it is complete. Don’t just settle for calcium and vitamin D. At the very least you will want your supplement to contain magnesium and vitamin K. I personally recommend that it also contain zinc, copper, and manganese as well.
  • Your calcium supplement will be best utilized if taken between meals.
  • Your calcium supplement will be best utilized if you don’t take more than 500 mg at a time.
  • In most cases there is no need for more than the DV of calcium.

Let’s review the connection between calcium and breast cancer risk reduction.

 

The Bottom Line

  • A recent study has shown that increasing calcium intake reduces the risk of breast cancer. The effect of calcium intake on breast cancer risk was much greater for premenopausal women (25% risk reduction) than it was for postmenopausal women (6% risk reduction).
  • While the effect of calcium alone on breast cancer risk was relatively modest,  it is likely to be an important component of a holistic approach for reducing breast cancer risk.  Additional recommendations of the Mayo Clinic and American Cancer Society for reducing breast cancer risk are contained in the article above.
  • While many experts recommend getting your calcium from food alone, a careful analysis of food sources of calcium clearly shows how difficult that is for most people.
  • Calcium supplements are a safe and effective way to make sure you are getting the calcium you need. In the article above, I describe the optimal design of a calcium supplement and how to take a calcium supplement for optimal utilization.

 

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure or prevent any disease.

Omega-3 And Blood Pressure: The Good News

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Will Fish Oil Lower Your Blood Pressure?

Author: Dr. Stephen Chaney

 

omgega-3 and blood pressureIs there a relationship between omega-3 and blood pressure we should understand to for health benefits?

High blood pressure is a killer! It can kill you by causing heart attacks, strokes, congestive heart failure, kidney failure and much more.

High blood pressure is a serial killer. It doesn’t just kill a few people. It kills lots of people. The American Heart Association estimates that high blood pressure directly or indirectly caused 363,000 deaths in 2010. That is almost 1 person every second and represents a 41% increase from 2000. It’s because high blood pressure is not a rare disease.

  • 31% of Americans have high blood pressure, also called hypertension, (defined as a systolic blood pressure of 140 mm Hg or more or a diastolic blood pressure of 90 mm Hg or more).
  • Another 30% of Americans have prehypertension (systolic blood pressure of 120-139 mm Hg or diastolic blood pressure of 80-89 mm Hg).

That’s over 61% of Americans with abnormal blood pressure!

High blood pressure is a silent killer. That’s because it is a very insidious disease that sneaks up on you when you least expect it. Systolic blood pressure increases 0.6 mm Hg/year for most adults over 50. By age 75 or above 76-80% of American adults will have high blood pressure.  Even worse, many people with high blood pressure have no symptoms, so they don’t even know that their blood pressure is elevated. For them the first symptom of high blood pressure is often sudden death.

Blood pressure medications can harm your quality of life. Blood pressure medications save lives. However, like most drugs, blood pressure medications have a plethora of side effects – including weakness, dizziness, fainting, shortness of breath, chest pain, nausea, diarrhea or constipation, heartburn, depression, heart palpitations, and even memory loss . The many side effects associated with blood pressure medications lead to poor compliance, which is probably why only 47% of patients with high blood pressure are adequately controlled.

You do have natural options. By now you are probably wondering whether there are natural approaches for controlling your blood pressure that are both effective and lack side effects. The answer is a resounding YES! I’ll outline a holistic natural approach for keeping your blood pressure under control in a minute, but let me start with the good news about omega-3 fatty acids.

 

The Good News About Omega-3 and Blood Pressure

omega-3s lower blood pressureWhat’s the good news about omega-3 and blood pressure?  We’ve known for some time that omega-3 fatty acids helped lower blood pressure, but two recent studies have really highlighted just how strong the effect of omega-3s on lowering blood pressure is.

The first study (Miller et al, American Journal of Hypertension, 27: 885-896, 2014) was a meta-analysis of 70 randomized, placebo-controlled clinical trials of long chain omega-3 (EPA + DHA) supplementation and blood pressure.

Here are the results of this study:

  • In the group with normal blood pressure at the beginning of the study EPA + DHA supplementation decreased systolic blood pressure by 1.25 mm Hg.
  • Given that systolic blood pressure rises an average of 0.6 mm Hg/year in adults over 50, the authors estimated that omega-3 supplementation alone would delay the onset of age-related high blood pressure by 2 years.
  • In the group with elevated blood pressure not taking medication at the beginning of the study, EPA + DHA supplementation decreased systolic blood pressure by an impressive 4.51 mm Hg and diastolic blood pressure by 3.05 mm Hg.
  • The authors noted that this decrease in systolic blood pressure could “prevent an individual from requiring medication [with all its side effects] to control their hypertension” or decrease the amount of medication required.

However, the doses of omega-3s used in these studies ranged from 1 to over 4 grams/day (mean dose = 3.8 grams/day). That sparked a second study (Minihane et al, Journal of Nutrition, 146: 516-523, 2016) to see whether lower levels of omega-3s might be equally effective. This study was an 8 week double-blind, placebo-controlled study comparing the effects of 0.7 or 1.8 grams of EPA + DHA per day (versus an 8:2 ratio of palm and soybean oil as a placebo) on blood pressure.

Here are the results of this study:

  • In the group with normal blood pressure at the beginning of the study, EPA + DHA supplementation caused no significant decrease in blood pressure. This could be due to the smaller number of subjects or the lower doses of EPA + DHA used in this study.
  • In the group with elevated blood pressure not taking medication at the beginning of the study, EPA + DHA supplementation decreased systolic blood pressure by 5 mm Hg and, the effect was essentially identical at 0.7 grams/day and 1.8 grams/day.
  • The authors concluded “Our data suggest that increased EPA + DHA intakes of only 0.7 grams/day may be an effective strategy for blood pressure control.”

A Holistic Approach To Blood Pressure Control

 

lower blood pressure dietThe latest information about omega-3 and blood pressure is good news indeed, but that’s not the only natural approach that lowers blood pressure. You have lots of other arrows in your quiver. For example:

  • The DASH diet (A diet that has lots of fresh fruits and vegetables; includes whole grains, low fat dairy, poultry, fish, beans, nuts and oils; and is low in sugar and red meats) reduces systolic blood pressure by 5-6 mm Hg. [Low sodium, low sodium/high-potassium, low-sodium/low-calorie, low-calorie and Mediterranean diets also lower blood pressure, but not by as much as the DASH diet].
  • Reducing sodium by about 1,150 mg/day reduces systolic blood pressure by 3-4 mm Hg.
  • Reducing excess weight by 5% reduces systolic blood pressure by 3 points.
  • Doing at least 40 minutes of aerobic exercise 3-4 times/week reduces systolic blood pressure by 2-5 mm Hg.

benefits of nitratesIf you’ve been keeping track, you’ve probably figured out that a holistic lifestyle that included at least 0.7 grams/day of long chain omega-3s (EPA + DHA) plus everything else in the list above could reduce your systolic blood pressure by a whopping 18-22 mm Hg.

That’s significant because,as the graphic on the right shows, the CDC estimates that reducing high systolic blood pressure by only 12-13 mm Hg could substantially decrease your risk of disease.

 

A Word Of Caution

While holistic approaches have the potential to keep your blood pressure under control without the side effects of medications, it is important not to blindly rely on holistic approaches alone. There are also genetic and environmental risk factors involved in determining blood pressure. You could be doing everything right and still have high blood pressure. Plus, you need to remember that high blood pressure is a silent killer that often doesn’t have any detectable symptoms prior to that first heart attack or stroke.

My recommendations are:

  • Monitor your blood pressure on a regular basis.
  • If your blood pressure starts to become elevated, consult with your doctor about starting with natural approaches to bring your blood pressure back under control. Doctors are fully aware of the side effects of blood pressure medications, and most doctors are happy to encourage you to try natural approaches first.
  • Continue to monitor blood pressure as directed by your doctor. If natural approaches are insufficient to bring your blood pressure under control, they will prescribe the lowest dose of blood pressure medication possible to get your blood pressure where it needs to be.
  • Don’t stop making holistic lifestyle choices to reduce blood pressure just because you are on medication. The more you do to keep your blood pressure under control, the less medication your doctor will need to use (That means fewer side effects).

 

The Bottom Line

 

  • Recent studies have shown that supplementation with as little as 0.7 grams of long chain omega-3s (EPA + DHA) per day is sufficient to decrease systolic blood pressure by ~ 5 mm Hg in people with untreated hypertension (high blood pressure). If your blood pressure is currently in the normal range, it is not yet clear how much EPA + DHA you need to keep it there. That may require a higher dose.
  • When you combine that with other natural approaches such as the DASH diet, reducing sodium, losing weight, and increasing exercise you can decrease blood pressure by 18-22 mm Hg.
  • The CDC estimates that is enough to substantially decrease your risk of stroke, coronary heart disease, memory loss, kidney disease, erectile dysfunction, death from cardiovascular disease, and death from any cause.
  • The authors of these recent studies concluded that holistic lifestyle changes including substantially increasing omega-3 intake have the potential to significantly delay the onset of age-related hypertension and may allow people with elevated blood pressure to eliminate or substantially reduce the use of blood pressure medications – with their many side effects.
  • High blood pressure is a silent killer. It is important to monitor your blood pressure regularly. If it becomes elevated, work with your doctor to find the balance of natural approaches and medication that is right for you.

 

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure or prevent any disease.

PAHs Contaminate Supplements?

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Do Your Supplements Contain Carcinogens?

Author: Dr. Stephen Chaney

 

pahs in supplementsMost of us take supplements to improve our health. We count on those supplements being pure and effective. We don’t expect the supplements we take to contain carcinogenic (cancer causing) contaminants. However, that expectation appears to be unfounded. A recent study found that 72% of supplements tested were contaminated with a particularly dangerous class of cancer causing chemicals called polycyclic aromatic hydrocarbons (PAHs)

Where Do PAHs Come From  andWhy Are TheyDeadly?

Polycyclic aromatic hydrocarbons (PAHs) are produced by incomplete combustion of organic materials. Major environmental sources of PAHs are incomplete burning of gasoline, coal and other fuels. Unfortunately, automobile exhaust, coal burning power plants, and exhaust from factories are almost ubiquitous in today’s world, resulting in significant PAH contamination of our air, water, and soil. The unfortunate truth is that we all live in an increasingly dirty and toxic environment.

pahs can come from highwayAs you might imagine, cigarette smoke is the #1 source of PAHs in humans. However, foods are a major route for PAH exposure in humans as well. There are many food sources of PAHs. For example,

  • Grilling, roasting and frying foods, especially meats, at high temperatures creates PAHs.
  • Smoking fish or meats creates PAHs.
  • Barbecuing meats creates PAHs.
  • Even plant-based foods can contain PAHs if the soil, air or water they were grown in was contaminated.
  • PAHs can be introduced into supplements if any of their ingredients are dried at high temperatures as part of the processing procedure.

By now you are probably realizing that it is not just our environment that is increasingly being contaminated with PAHs. We are all becoming contaminated with PAHs as well. Our bodies are becoming toxic waste dumps.

Unfortunately, PAHs are not innocuous chemicals. Perhaps the best studied and deadliest of the PAHs is a compound called benzo[a]pyrene. It is classified as a class 1 carcinogen and mutagen by the IARC (International Agency for Research on Cancer). Perhaps some explanation is in order:

  • The IARC is an international organization that is charged with evaluating the scientific evidence for the carcinogenicity of various chemicals. It also sets upper limits for safe exposure to those chemicals.
  • Class 1 carcinogens are compounds that the IARC has classified as definitely carcinogenic to humans. Simply put, the IARC considers the scientific evidence to be overwhelming that those compounds are carcinogens.

To date only 118 compounds have been blacklisted by the IARC as class 1 carcinogens and benzo[a]pyrene is one of them. However, many of the other, less studied, PAHs are classified as probable carcinogens by the IARC.

Unfortunately, in most countries of the world (including the United States), PAH limits in food and supplements are unregulated. Because they are unregulated, many supplement companies don’t even test for them. That is unfortunate because a recent study shows that many supplements are contaminated with high levels of PAHs, and their manufacturers didn’t even know it.

Do Your Supplements Contain PAHs or Other Carcinogens?

carcinogens in supplementsThe European Union has taken the lead in regulating PAH levels. They have used the IARC guidelines to create upper allowable limits for PAHs in food and supplements. Separate standards were set for benzo[a]pyrene and the total of the four most common PAH contaminants (benzo[a]anthracene, benzo[a]pyrene, benzo[b]fluoranthrene, and chrysene). Those new regulations just went into effect April 1st 2016.

To gauge the impact of these new regulations on the supplement industry, the EU asked the European Union Reference Laboratory to measure the levels of PAH contamination in supplements sold in the EU prior to the implementation of the new regulations. Because vitamin and mineral supplements are seldom contaminated with PAHs, they were excluded from the study.

The EU Reference Laboratory started collecting a wide range of herbal and botanical supplements, fish and edible oil food supplements, and propolis and other bee supplements sold in the EU in 2013. The Reference Laboratory analyzed 94 different supplements for PAH contamination, and the results of these analyses were published in October 2015 (Z. Zelinkova and T. Wenzyl, Food Additives & Contaminants: Part A, 32: 1914-1926, 2015).

[In case you, like me, were wondering what propolis is, it is a resin like substance that bees use as a glue to hold their hives together. WebMD states that it may have some use as a topical agent for cold sores, genital herpes, and after mouth surgery, but that any other uses are unproven. However, if you visit websites for propolis products you find it in capsules and liquids for internal consumption. You are told that it cures bacterial and fungal infections, cures viral infections like AIDs, cures cancer, and removes warts.]

The results of their analysis were pretty scary:

  • 72% of the supplements tested exceeded EU limits for the four most common PAH contaminants, and 52% exceeded EU limits for benzo[a]pyrene.
  • Propolis and spirulina were the most heavily contaminated supplements. Valerian and St. John’s Wort had moderately high levels of contamination, and some samples of bee pollen, sea buckthorn oil, barley greens, Echinacea, and Ginko far exceeded EU standards.
  • If consumers took the recommended dosage of the two most contaminated products (Premium Spirulina and Propolis Intense) they would more than double their daily intake of PAHs and far exceed what the IARC considers safe.
  • Fish oils generally had low levels of PAH contamination. The authors speculated this may be because fish have the ability to metabolize PAHs. However, other edible oils, particularly sea buckthorn oil and a mixture of garlic oil with soybean and sunflower oils did exhibit significant PAH contamination. The authors speculated that this PAH contamination may have been introduced during the processing of these oils.

Why The PAH and Contamination Problem Is Worse Than You Thought

worseYou might be thinking what could be worse than 72% of supplements being contaminated with cancer causing PAHs? Here is some food for thought.

  • PAHs are just the tip of the iceberg. Many supplements are also contaminated with PCBs and heavy metals. For example:
  • Fish oil is often contaminated PCBs.
  • Rice protein and other rice-derived ingredients are often contaminated with lead and/or mercury.
  • The US regulates PAHs in our water supply, but does not currently regulate PAHs in our supplements. That means that manufacturers that make products primarily for consumption in the US have no incentive to test their products for PAH contamination. Most of them have no idea whether their products are safe or not.
  • There is no guarantee that even products labeled Certified Organic and Non-GMO are free of PAH contamination. For example:
  • Organic certification just means that the crop was raised using organic methods. No analysis of purity is required to assure that the crop had not been inadvertently contaminated. The same is true of non-GMO certification. No analysis of purity is required.
  • Organically grown, non-GMOcrops that are used as ingredients for supplements can still be contaminated if the air, soil or water is contaminated from any nearby pollution source. For example, ground water pollution is the major source of the heavy metal contamination often seen in rice-derived ingredients.
  • Organically grown, non-GMO crops can even become contaminated by PAHs if they are grown next to a busy highway.
  • Even if the ingredients are pure to begin with, PAH contamination can be introduced during processing.

What does all of this mean to us? It means that it is absolutely imperative that we do our due diligence and only choose supplement manufacturers whose quality control standards far exceed what is required of the industry. Our health just may depend on it.

 

The Bottom Line

 

  • A recent study has reported that 72% of herbal and botanical supplements, fish and edible oil food supplements, and supplements derived from bees sold in the EU were contaminated with high levels of cancer causing polycyclic aromatic hydrocarbons (PAHs).
  • The levels of PAHs in many of these products far exceeded standards recently enacted by the EU. If those supplements were taken as recommended, the daily intake of PAHs by people consuming them would also far exceed the safe limits of exposure to these toxic chemicals set in place by the International Agency for Research on Cancer.
  • While all of this sounds bad enough, the news is even worse for most of us living in the US.
  • PAHs are just the tip of the iceberg. Many supplements are also contaminated with PCBs and heavy metals.
  • The US regulates PAHs in our water supply, but does not currently regulate PAHs in our supplements. That means that manufacturers that make products primarily for consumption in the US have no incentive to test their products for PAH contamination. Most of them have no idea whether their products are safe or not.
  • There is no guarantee that even products labeled Certified Organic and Non-GMO are free of PAH contamination.
  • What does all of this mean to us? It means that it is absolutely imperative that we do our due diligence and only choose supplements manufacturers whose quality control standards far exceed what is required of the industry. Our health just may depend on it.  Remember, PAHs are not the only potential problem.

 

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure or prevent any disease.

Can Supplementation Improve Teen Behavior?

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Author: Dr. Stephen Chaney

 

can supplementation improve teen behaviorAll teenagers can be a handful at times. Experts tell us that their raging hormones are to blame, but could their junk food diets play a role as well? If so, would something as simple as supplementation improve teen behavior?

This has been a controversial issue, with some studies saying yes and other studies saying no. With that in mind I thought I would share a recent study that concludes supplementation may improve behavior in teens. While this one study will not resolve the controversy, it does provide some insight into why the results of previous studies have been so contradictory.

Can Supplementation Improve Teen Behavior?

This study (Tammam et al, British Journal of Nutrition, 115: 361-373, 2016) enrolled 196 healthy teens aged 13-16 from a large public school in London. The school was located in an economically depressed area of London where a large proportion of the adults were out of work and had no formal education. Many of the children attending that school had adverse home environments and poor nutrition.

This is an important point. The scientists running the study had specifically chosen a teenage school population that was likely to have poor nutritional status. This poor nutritional status was confirmed by blood samples taken at the beginning of the study which showed the teens were low in iron, folate, vitamin D, vitamin C and omega-3 fatty acids – all of which are important for brain health.

teen behvaviorThe students were given either a comprehensive multivitamin plus 541 mg of omega-3 fatty acids (containing 165 mg EPA and 116 mg DHA) or matched placebos for one school term (12 weeks). The study was fully blinded in that neither the students nor their teachers knew who had received the supplements and who had received the placebo.

Blood test taken at the end of the study showed that students taking the supplements had significantly higher blood levels of folate, vitamin C, vitamin D, and omega-3 fatty acids (iron levels remained unchanged) while those nutrient levels were unchanged in the placebo group.

Teachers rated the student’s behavior using the Connors Clinical Index Teacher Rating Scale before the study began and again during the last week of the study. The results were clear cut. Behavior improved in the group receiving the supplements and worsened in the group receiving the placebo.

The researchers also looked at disciplinary infringement logs (you can think of those as disciplinary problems severe enough to send the kids to the principal’s office), but the number of disciplinary incidents per child were too low to draw any statistically significant conclusions.

Why Are Supplementation and Teen Behavior Studies So Contradictory?

diet and behaviorAs I said at the beginning of this article, previous nutritional intervention trials looking at teen behavior problems have been conflicting. Some, like this study, have shown a clear benefit of supplementation on teenage behavior. Others have shown no benefit at all.

Most experts tend to treat all studies on a particular topic as equal. They throw all of the studies into a statistical pot and look at the average effect. When studies are contradictory, as is the case for studies looking at the effect of supplementation on teenage behavior, the positive and negative studies cancel each other out and the net effect is often close to zero. When that happens experts generally consider the intervention as “unproven”.

That is a valid approach, but I also like to look for patterns. I like to ask why the studies have come to such contradictory conclusions.

When you evaluate the studies on supplementation and teenage behavior carefully, a pattern starts to emerge. If most of the teenagers in the study have poor nutritional status or have severe behavior problems (such as teenagers in prison), the studies generally show a benefit of supplementation. If most of the teens in the study have good nutritional status at the beginning of the study, the results of supplementation are very difficult to detect. Similarly, if most of the teens in the study are well behaved to begin with, supplementation appears to have little effect.

What Does This Mean For Your Teenager(s)?

The causes of teenage behavior problems are many. Poor nutrition may play a significant role, but genetics, hormones, home environment and school environment are important as well. However, teen eating habits are often less than ideal. If you have a teenager with behavior problems and poor eating habits, supplementation is an inexpensive intervention that may just contribute to better behavior.   So, can supplementation improve teen behavior?  Maybe.

 

The Bottom Line

  • The study was performed in an economically depressed school district where many children suffered from poor nutritional status. Blood test taken at the beginning of the study showed that the students were low in iron, folate, vitamin C, vitamin D, and omega-3 fatty acids. Blood tests taken at the end of the study showed improved nutritional status for every nutrient except iron in the group taking supplements.
  • When you combine this study with previous studies, a pattern emerges.  If most of the teenagers in the study have poor nutritional status or have severe behavior problems (such as teenagers in prison), the studies generally show a benefit of supplementation. If most of the teens in the study have good nutritional status at the beginning of the study, the results of supplementation are difficult to detect. Similarly, if most of the teens in the study are well behaved to begin with, supplementation appears to have little effect.
  • What does all of this mean to the general public? Nutritional status is just one component of teenage behavior. Hormones, genetics, home environment and school environment are important as well. However, teen eating habits are often less than ideal. If you have a teenager with behavior problems and poor eating habits, supplementation is an inexpensive intervention that may just contribute to better behavior.

 

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure or prevent any disease.

Antioxidants and Aging

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Author: Dr. Stephen Chaney

 

antioxidant agingModern medicine has helped mankind greatly extend our lifespan, but what about our “healthspan”? Aging is often associated with major degenerative diseases and loss of physical and mental functioning. As the saying goes: “Aging isn’t for sissies”. But, what if you could live healthy into your 80s and 90s? What if you had the health to truly enjoy the wisdom that comes with your years of experience?  In this article we will explore antioxidants and aging.

While healthy aging is a very personal issue for all of us in our golden years, it is a very important societal issue as well. The United Nations estimates that by 2050 more than 1/3 of the population of developed countries will be over 60. Unless we can find a way to preserve the health of these older adults, health care costs will bankrupt even the richest of countries.

That’s why the recently published study on the effect of antioxidant supplements on healthy aging in French adults (Assmann et al, American Journal of Epidemiology, 182: 694-704, 2015) is so interesting.

How Was The Study Designed?

studyThis study was a follow-up to the “Supplementation With Antioxidant Vitamins and Minerals” study that was conducted in France during 1994-2002. That was a double blind, placebo controlled study in which participants were given either a placebo or a supplement containing 120 mg of vitamin C, 6 mg of beta-carotene, 30 mg of vitamin E, 100 ug of selenium, and 20 mg of zinc every day for an eight-year period. These nutrient levels were designed to be equivalent to the quantities provided by a balanced diet rich in fruits and vegetables.

The follow-up study was conducted approximately 5 years later with 3,996 of the original participants. The investigators specifically selected participants who were disease free when they entered the original study. These study participants were equally divided between men and women and had an average age of 65.3 years.

The participants were put through a battery of screens and assigned a “healthy aging score” based on:

  • Absence of cancer, heart disease and diabetes
  • Good physical and cognitive function
  • No limitations in activities associated with daily living
  • No depressive symptoms
  • No health-related limitations in social life
  • Good overall perceived health
  • No function-limiting pain

In short those participants with a high healthy aging score had good health and good quality of life.

Are Antioxidants the Secret to Healthy Aging?

antioxidant nutrientsWhen the investigators looked at the group as a whole, the results were pretty discouraging:

  • Antioxidant supplementation provided no significant benefit to the population as a whole.
  • Antioxidant supplementation also provided no significant benefit to the women in the group.

However, when they looked at subgroups, the results were much more encouraging:

  • Antioxidant supplementation increased the probability of healthy aging by 18% for the men in the study.
  • For those participants with low serum vitamin C levels at the beginning of the study antioxidant supplementation increased the probability of healthy aging by 28%
  • For those participants with low serum zinc levels at the beginning of the study antioxidant supplementation increased the probability of healthy aging by 26%
  • For those participants consuming very few fruits and vegetables at the beginning of the study, antioxidant supplementation increased the probability of healthy aging by 17%

The conflicting results for men and women were puzzling, but the investigators pointed out that very few women had low serum vitamin C status at the beginning of the study, while 25% of the men had low serum vitamin C levels at the beginning of the study. The investigators speculated that supplementation may have been less effective in women simply because they had better diets than the men in the study. That certainly wouldn’t surprise me.

What Are The Strengths And Weaknesses Of This Study?

Let’s start with the strengths. This is the very first double-blind, placebo-controlled study to look at the role of antioxidant nutrients in healthy aging. A number of previous studies looking at the effect of antioxidant nutrients on individual components of aging have given conflicting results. The investigators pointed out that this study may have shown more beneficial effects of antioxidants than previous studies because:

  • Most previous studies have been relatively short in duration. This was an 8-year study with a 5-year follow-up period (total study length = 13 years).
  • Most previous studies did not measure baseline intake of the nutrients. This study shows that individuals with low baseline intake or low serum levels at the beginning of the study are significantly more likely to benefit from supplementation.
  • Most previous studies have measured the effects of single antioxidant nutrients, or at most combinations of 2 or 3 antioxidant nutrients. This study used a combination of 5 different antioxidant nutrients. The synergy between these nutrients may have increased the magnitude of the observed benefits.

The weaknesses of the study are also pretty apparent.

  • Since it is the first study of its kind, it does need to be validated by additional studies.
  • There is no universally accepted index for healthy aging (This is a problem for aging research as a whole, not just this study).
  • The participants in the study were not evaluated for healthy aging criteria at the beginning of the study so we have no idea how their healthy aging score changed over time.
  • The beneficial effect of antioxidant nutrients, while significant, were relatively small. You are obviously not going to live healthy to 100 by consuming antioxidant supplements alone.

Antioxidants and Aging:  Will Antioxidant Nutrients Help You?

aging gracefullyThis study does suggest that antioxidant supplements may help you achieve healthy aging. This study also makes three other very important points:

  • A holistic approach to supplementation – one involving multiple antioxidant nutrients – is much more likely to be beneficial than individual antioxidant supplements.
  • Supplementation is most likely to be beneficial for those individuals who are consuming a poor diet.
  • Supplementation is also most likely to be beneficial for those individuals who have low serum level of essential nutrients. This can be due to poor diet, but low serum levels of individual nutrients can also be caused by individual differences in metabolism or genetic make-up.

However, as noted above:

  • The study has some weaknesses and needs to be repeated.
  • The beneficial effects of antioxidant nutrients were relatively small.

That means that holistic approaches to healthy aging are more likely to be beneficial than individual supplements. Based on what we currently know a holistic approach to healthy aging includes:

  • Consuming a combination of a balanced diet and supplementation that provides sufficient levels of all the essential nutrients, not just the antioxidant nutrients. This would include things like omega-3 fatty acids and polyphenols.
  • Avoiding saturated and trans fats, excess sugar, red and processed meats, which may have bad effects on your health.
  • Controlling your weight.
  • Staying mentally and physically active.
  • Maintaining strong social networks.
  • Maintaining a positive outlook on life.

 

The Bottom Line

  • A recent study suggests that antioxidant supplements may help you achieve healthy aging. This study also makes two other very important points:
  • A holistic approach to supplementation – one involving multiple antioxidant nutrients – is much more likely to be beneficial than individual antioxidant supplements.
  • Supplementation is most likely to be beneficial for those individuals who are consuming a poor diet and/or have low serum levels of essential nutrients.
  • Since the beneficial effect of antioxidant nutrients on healthy aging was relatively small, this suggests the antioxidant nutrients are just one part of a holistic approach to healthy aging that includes.
  • Consuming a combination of a balanced diet and supplementation that provides sufficient levels of all the essential nutrients, not just the antioxidant nutrients. This would include things like omega-3 fatty acids and polyphenols.
  • Avoiding saturated and trans fats, excess sugar, red and processed meats, which may have bad effects on your health.
  • Controlling your weight.
  • Staying mentally and physically active.
  • Maintaining strong social networks.
  • Maintaining a positive outlook on life.

 

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure or prevent any disease.

Do B Vitamins Reduce Heart Disease Risk?

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What Role Do B Vitamins Play in a Heart Healthy Lifestyle?

Author: Dr. Stephen Chaney

b vitamins reduce heart attack riskTwo weeks ago I shared some studies that challenge the claim that vitamin E doesn’t reduce heart attack risk. To close out “Heart Health” month, I want to share some information that may change how you think about B vitamins and heart disease risk. Once again, you’ve seen the headlines: “B Vitamins Do Not Reduce the Risk of Heart Disease”. In fact, these headlines have been repeated so many times that virtually every expert thinks that it has to be true. Once again, I’m going to share some information with you that I learned from a seminar by Dr. Jeffrey Blumberg who disagrees with this commonly held belief.

Dr. Blumberg is a Professor in the Friedman School ofNutrition Science and Policy at Tufts. Dr. Blumberg has over 200 publications in peer-reviewed scientific journals. He is considered one of the world’s top experts on supplementation, and his specialty is conducting and analyzing clinical studies. He believes that the media has seriously misinterpreted the studies on B vitamins and heart disease risk. You might call this “The Rest of the Story” because you (and your doctor) definitely did not hear this part of the story in the news.

Do B Vitamins Reduce Heart Disease Risk?

heart disease in menThe study in question is called the “Heart Outcomes Prevention Evaluation-2“. In that study a group of middle aged men and women received 2.5 mg of folate, 50 mg of vitamin B6 and 1 mg of vitamin B12 versus a placebo and were followed for an average of 5 years.

The headlines that you may have seen said “B vitamins do not reduce the risk of major cardiovascular events in patients with vascular disease”. But, the headlines did not tell the whole story.

In the first place, that was only true for heart attacks and cardiovascular death. Strokes were reduced by 25%. I don’t know about you, but I consider strokes to be fairly major.

However, even when we focus on heart attacks and cardiovascular deaths the headlines didn’t tell the whole story. You see, even the best intentioned studies sometimes contain fatal flaws that aren’t obvious until after the study has been completed.

The Flaws In The Study

flawsThere were two major flaws in this study.

Flaw #1 was that 70% of the study subjects were eating foods fortified with folate and had adequate levels of that nutrient in their bloodstream before the study started.

For those people who were already getting enough folate in their diet, B vitamin supplementation didn’t make much of a difference. However, for those people not getting adequate levels of folate in their diet, B vitamin supplementation decreased their risk of heart disease by ~15%.

Flaw #2 was that ~90% of the people in the study had a history of coronary artery disease and most of them were already on cholesterol lowering medications.

To understand why this is a problem you have to understand both the proposed mechanism by which B vitamin supplementation has been proposed to lower the risk of heart disease AND how the cholesterol lowering drugs work.

Deficiencies of folate, B6 and B12 are thought to increase the risk of heart disease because the B vitamin deficiency causes an increase in homocysteinelevels in the blood, and high homocysteine levels are thought to increase inflammation – which is a risk factor for heart disease.  So supplementation with folate, B6 and B12 has been proposed to decrease heart disease risk by decreasing inflammation.

The problem is that the most commonly used cholesterol lowering medications also decrease inflammation.So you might not be surprised to learn that those people who had a history of coronary artery disease(and were taking cholesterol lowering medication that reduces inflammation) did not receive much additional benefit from B vitamin supplementation.

For those people in the study who were not taking cholesterol lowering medication, B vitamin supplementation also reduced their risk of heart attacks by ~15% – but there were too few people in that group for the results to be statistically significant.

So the headlines from this study really should have said “B vitamins do not reduce the risk of heart attacks or cardiovascular deaths in people who are already getting adequate folate from their diet or in people who are taking drugs that reduce the bad effects of B vitamin deficiency”. But that kind of headline just wouldn’t sell any newspapers.

What Does This Study Mean For You?

There are two very important take-home lessons from this study.

Lesson #1:  Once again this study makes the point that supplementation makes the biggest difference when people have an increased need. The studies discussed in Vitamin E and Heart Disease  two weeks ago illustrated increased need because of age, pre-existing disease, and genetic predisposition. This study illustrated increased need because of inadequate diet.

Lesson #2:  This study also illustrates a problem that is becoming increasingly common in studies of supplementation. It is considered unethical to not provide participants in both groups with what is considered the standard of care for medical practice. In today’s world the standard of care includes multiple drugs with multiple side effects, and some of those drugs may have the same mechanism of action as the supplement.

I have discussed this problem in the context of omega-3 fatty acids and heart disease in a previous “Health Tips From the Professor,”  Is Fish Oil Really Snake Oil?   In many cases it is no longer possible to ask whether supplement X reduces the risk of a particular disease. It is now only possible to ask whether supplement X provides any additional benefit for patients who are taking multiple drugs, with multiple side effects. That’s not the question that many of my readers are interested in.

 

The Bottom Line

  • Headlines have proclaimed for years the “B Vitamins Do Not Reduce Heart Disease Risk”. Dr. Jeffrey Bloomberg of Tufts University has reviewed one of the major studies behind this claim and found the headlines to be misleading.
  • For example, the study showed that B vitamin supplementation reduced strokes by 25%, which is a pretty significant finding in itself.
  • When he analyzed the portion of the study looking at heart attacks, he found two major flaws:

#1:  70% of the people in the study were already getting adequate amounts of B vitamins from their diet and would not be expected to benefit from supplementation. For the 30% who weren’t getting adequate amounts of B vitamins from their diet, supplementation reduced their risk of heart attack by 15%.

#2:  90% of the people in the study were taking a drug that masks the beneficial effects of B vitamin supplementation. For the 10% who weren’t taking the drug, supplementation with B vitamins also reduced their risk of heart attack by 15%, but there were too few people in that group for the results to be statistically significant.

Obviously, there were only a handful of people in the study who weren’t getting enough B vitamins from their diet AND weren’t on medication, so we have no idea what the effect of B vitamin supplementation was in that group.

  • Once again this study makes the point that supplementation makes the biggest difference when people have an increased need. The studies discussed in “Health Tips From the Professor” two weeks ago illustrated increased need because of age, pre-existing disease, and genetic predisposition. This study illustrated increased need because of inadequate diet.
  • This study also illustrates a problem that is becoming increasingly common in studies of supplementation. It is considered unethical to not provide participants in both groups with what is considered the standard of care for medical practice. In today’s world the standard of care includes multiple drugs, some of which may have the same mechanism of action as the supplement.

In many cases it is no longer possible to ask whether supplement X reduces the risk of a particular disease. It is now only possible to ask whether supplement X provides any additional benefit for patients who are taking multiple drugs, with multiple side effects. That’s not the question that many of my readers are interested in.

 

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure or prevent any disease.

Vitamin E And Heart Disease

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Does Vitamin E Reduce Heart Attack Risk?

Author: Dr. Stephen Chaney

vitamin e and heart diseaseSince February is “Heart Health Month”, I thought I would share some information with you that might change how you think about vitamin E and heart disease risk. You’ve seen the headlines: “Vitamin E Does Not Reduce the Risk of Heart Disease”. In fact, these headlines have been repeated so many times that virtually every expert thinks that it has to be true. Let me share the opinion of one expert who disagrees. This week I’m going to share some information with you that I learned from a seminar by Dr. Jeffrey Blumberg from Tufts University.

But first let me tell you who Dr. Blumberg is. Dr. Blumberg is a Professor in the Friedman School of Nutrition Science and Policy at Tufts. Dr. Blumberg has over 200 publications in peer-reviewed scientific journals. He is considered one of the world’s top experts on supplementation.

Now back to what I learned at his seminar. Dr. Blumberg’s specialty is conducting and analyzing clinical studies, and his perspective on some very influential clinical studies is a bit different from what you may have heard from media reports. He believes that the media has seriously misinterpreted several recent studies. You might call this “The Rest of the Story” because you (and your doctor) definitely did not hear this part of the story in the news.

Does Vitamin E Reduce Heart Disease Risk In Women?

cardiovascular disease in womenLet’s start with vitamin E and the risk of cardiovascular disease in women. The most influential study on this subject was the Women’s Health Study (Lee et al., JAMA, 294:56-65, 2005). This was a major study in which 39,876 women were given either 600 IU of vitamin E every other day or a placebo and followed for 10 years.

The headlines said “Vitamin E Supplements Do Not Reduce Risk Of Cardiovascular Death, Heart Attack And Stroke In Women”. That was true if you looked at the total population of women in the study.

But Dr. Blumberg pointed out that when you looked at women who were 65 or older in that study vitamin E supplementation caused a…

  • 24% decrease in cardiovascular deaths,
  • 26% decrease in major cardiovascular events,
  • 21% decrease in venous thromboembolism (blood clots forming in the veins),

…and all of these decreases were statistically highly significant. That’s important because the risk of heart disease in pre-menopausal women is extremely low. It’s the over 65 group who have a high risk of heart disease.

Perhaps the headlines should have said: “Vitamin E reduces the risk of cardiovascular disease and cardiovascular deaths in those women at high risk of heart attacks”. But, of course, they didn’t. Perhaps that wasn’t considered newsworthy.

Other Studies On Vitamin E and Heart Disease Risk In Women

heart disease riskIf this were the only study suggesting the vitamin E might benefit women at high risk of having a heart attack or stroke, it might be easy to dismiss it, but it’s not the only study showing this effect.

For example, a subsequent study called the “Women’s Antioxidant Cardiovascular Study” looked at the effect of 600 IU of vitamin E every other day on cardiovascular events in 8171 women health professionals (Cook et al, Archives of Internal Medicine, 167:1610-1618, 2007).

Once again the headlines said that vitamin E supplementation had no effect on cardiovascular events in women. But, when the authors looked at those women who already had cardiovascular disease at the beginning of the study (and were, therefore, at high risk of suffering a cardiovascular event during the study) vitamin E supplementation caused a 23% decreased risk of heart attack, stroke and cardiovascular death.

Another important study was the HOPE (Heart Outcomes Prevention Evaluation) study (Levy et al, Diabetes Care, 27: 2767, 2004). The overall study results were similar to several other recent trials – no significant effect of vitamin E supplementation on cardiovascular health in the population group as a whole.

However, by the time that study was performed it was clear that a particular genetic variation in the haptoglobin gene called the haptoglobin 2-2 genotype lead to a significant increase in oxidative damage to the vascular wall (the professor will collect your quizes at the end of this email).

When the data were reanalyzed by genotype, it became clear that people with the haptoglobin 2-2 genotype experienced a significant decrease in both heart attack and cardiovascular death with vitamin E supplementation. This finding has been confirmed by a subsequent double-blind, placebo-control study specifically designed to look at the cardioprotective effects of vitamin E in people with different haptoglobin genotypes (Milman et al, Arterioscler. Thromb. Vasc. Biol., 24: 136, 2008).

In short, the headlines from all three studies should have said: “Vitamin E reduces the risk of cardiovascular disease and cardiovascular deaths in those women at high risk of heart attacks” – and, it doesn’t appear to matter whether the increased risk is due to age, pre-existing disease, or genetic predisposition.

Does Vitamin E Reduce Heart Disease Risk In Men?

heart disease in menFor men the most influential study was called the “Physician’s Health Study II” (H. D. Sesso et al, JAMA, 300: 2123-2133, 2008). In this study male physicians aged 40-84 were invited to participate in a double-blind clinical trial in which they were randomly assigned into groups who were given 400 IU of vitamin E every other day or placebo. They were followed for an average of 8 years during which data on both total mortality and cardiovascular mortality were obtained.

Once again, the headlines read “Vitamin E Does NotPrevent Cardiovascular Disease in Men”. But let me tell you what Dr. Blumberg said so that you understand “The Rest of the Story”. It starts by looking at the selection process for the Physician Health Studies.

Dr. Sesso and his colleagues sent out a letter asking 261,248 male physicians in the US if they would be willing to participate in the study. Only 112,528 responded and, of those responding, only 59,272 indicated that they were willing to participate. Of those who said that they were willing to participate only 32,223 met the selection criteria.

The exclusion criteria eliminated anyone who already had suffered a heart attack, stroke, angina or was on a blood thinner – in other words those people who were at greatest risk of suffering a heart attack or stroke during the study.

Finally, the study had an 18 week “run in” period to eliminate those people who were unwilling or unable to comply with the study protocol. This eliminated another 10,000 participants, leaving only 22,071 participants – less than 10% of the original.

This is where it gets really interesting. Dr. Sesso and his colleagues used publicly available databases to evaluate total and cardiovascular mortality in each group (H. D. Sesso et al, Controlled Clinical Trials, 23: 686-702, 2002). It turns out that at each stage of the selection process the incidence of both total and cardiovascular mortality during the 8-year period decreased.

In fact, the doctors who were actually included in the study were 67% less likely to die from all causes and 73% less likely to die from cardiovascular disease than the male physician population as a whole.

The bottom line is that the selection process eliminated almost all of the physicians at significant risk of having a heart attack or stroke during the study. The only ones who were actually enrolled in the study were those physicians who were at very low risk for having a fatal heart attack or stroke – or dying from any cause – during the study.

So the headlines describing this study should have read “Vitamin E Does Not Prevent Cardiovascular Disease in Men Who Are At Very Low Risk Of Heart Attack And Stroke”.The irony is that there was nothing wrong with the design of the study. It’s probably just a male ego thing. Guys who were unhealthy just didn’t want to participate in a study that might show how unhealthy they really were.

What Does This Mean For You?

These studies illustrate the true story of supplementation. For those of us who are at low risk of disease, supplementation is just a form of health insurance. But for those of us at high risk of disease, supplementation can make a huge difference in our health. That increased risk can be due to many things, as we have seen in the studies above. It can be due to poor diet, age, pre-existing disease, and/or genetic predisposition.

The problem is that most of us don’t really know whether we are at low risk or high risk until it’s too late. For millions of Americans the first sign of heart disease is sudden death.

 

The Bottom Line

  • The experts have been saying for years that vitamin E does not reduce the risk of heart disease. That claim is true, if you look at the general population, most of which is at low risk of developing heart disease – at least during the time frame of the clinical studies. However, when you look at people who are at high risk of developing heart disease, the answer is different.
  • For example, when you look at clinical studies with women, vitamin E significantly decreased the risk of heart attacks in women who…
  • Were over 65,
  • Had pre-existing heart disease at the beginning of the study,
  • Or, had a genetic predisposition to heart disease.

The headlines from these studies should have read “Vitamin E reduces the risk of cardiovascular disease in those women at high risk of heart attacks”, but they didn’t.

  • For men the story is a bit different. The Physician’s Health Study is considered the definitive study on the subject. However, most of the unhealthy male physicians either didn’t enroll in the study or dropped out before its completion. In fact, the doctors who were actually included in the study were 67% less likely to die from all causes and 73% less likely to die from cardiovascular disease than the male physician population as a whole. The headlines describing this study should have read “Vitamin E Does Not Prevent Cardiovascular Disease in Men Who Are At Very Low Risk Of Heart Attack And Stroke”.
  • These studies illustrate the true story of supplementation. For those of us who are at low risk of disease, supplementation is just a form of health insurance. But for those of us at high risk of disease, supplementation can make a huge difference in our health. That increased risk can be due to many things, as we have seen in the studies above. It can be due to poor diet, age, pre-existing disease, and/or genetic predisposition.
  • The problem is that most of us don’t really know whether we are at low risk or high risk until it’s too late. For millions of Americans the first sign of heart disease is sudden death.

 

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure or prevent any disease.

Do Calcium Supplements Prevent Bone Fractures? – Part2: Preventing Osteoporosis

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Creating A “Bone Healthy” Lifestyle

Author: Dr. Stephen Chaney

prevent bone fracturesA recent study (Tai et al, British Medical Journal, BMJ/2015; 351:h4183 doi: 10.1136/bmj.h4183)reported that calcium supplementation for women over 50 resulted in only a very small increase in bone density, which translated into a very small (5-10%) decrease in the risk of bone fractures. They concluded that the standard RDA recommendation of 1,000 – 1,200 mg/day of calcium for adults over 50 is unlikely to help in  preventing osteoporosis or reducing the risk of bone fractures.

In last week’s issue of “Health Tips From the Professor,” I discussed the many flaws of the study. In brief:

  • The study was a meta-analysis of 51 published clinical studies. Normally, meta-analyses are very strong, but they have an “Achilles Heel” – something called the Garbage-In, Garbage-Out Simply put, this means that the meta-analysis is only as strong as the individual studies that went into it. The authors included 40 years of clinical studies in their meta-analysis, and most of those studies had an inadequate design by today’s standards.
  • The study also made a number of what I would call apples to oranges comparisons that were of questionable validity.

In this week’s issue of “Health Tips From The Professor”, I would like to explore the other side of the coin. I would like to consider the possibility that the study might be correct and discuss what that might mean for you.

What Is A “Bone Healthy” Lifestyle?

Despite the concerns I just mentioned, let’s assume for a minute that the study might just be correct in spite of its many flaws. Let’s assume that the “one size fits all” RDA recommendation of 1,000 – 1,200 mg/day of calcium if you are over 50 may actually be flawed advice. If so, perhaps it’s time to say good riddance! It may finally be time to put away the “magic bullet”, “one size fits all” thinking and start seriously considering holistic approaches.

Now that I have your attention, let’s talk about what you can do to prevent osteoporosis – and the role that supplementation should play. Let’s talk about a “bone healthy” lifestyle.

#1: Let’s start with supplementation:  Bone is not built with calcium alone. Bone contains significant amounts of magnesium along with the trace minerals zinc, copper and manganese – and all of these are often present at inadequate levels in the diet. Most of us know by now that vitamin D is essential for bone formation, but recent research has shown that vitamin K is also essential (Kanellakis et al, Calcified Tissue International, 90: 251-262, 2012). An ideal calcium supplement should contain all of those nutrients.

vegetable#2: Next comes diet:  Many of you probably already know that some foods are acid-forming and other are alkaline-forming in our bodies – and that it is best to keep our bodies on the alkaline side. What most of you probably don’t know is that calcium is alkaline and that our bones serve as a giant buffer system to help keep our bodies alkaline. Every time we eat acid-forming foods a little bit of bone is dissolved so that calcium can be released into the bloodstream to neutralize the acid. (My apologies to any chemists reading this for my gross simplification of a complex biological system).

Consequently, if we want strong bones, we should eat less acid-forming foods and more of alkaline-forming foods. Among acid-forming foods, sodas are the biggest offenders, but meat, eggs, dairy, and grains are all big offenders as well. Alkaline-forming foods include most fruits & vegetables, peas, beans, lentils, seeds and nuts. In simple terms, the typical American diet is designed to dissolve our bones. Calcium from diet or supplementation may be of little use if our diet is destroying our bones as fast as the calcium tries to rebuild them.

#3: Test your blood 25-hydroxyvitamin D level:  25-hydroxy vitamin D is the active form of vitamin D in our bloodstream. We need a sufficient (20-50 ng/mL) blood level of 25-hydroxy vitamin D to be able to use calcium efficiently for bone formation. We now know that some people who seem to be getting adequate vitamin D in their diet still have low 25-hydroxyvitamin D levels. In fact, various studies have shown that somewhere between 20-35% of Americans have insufficient blood levels of 25-hydroxy vitamin D. You should get your blood level tested. If it is low, consult with your health professional on how much vitamin D you need to bring your 25-hydroxy vitamin D into the sufficient range.

#4: Beware of drugs:The list of common medications that dissolve bones is a long one. Some of the worst offenders are anti-inflammatory steroids such as cortisone & prednisone, drugs to treat depression, drugs to treat acid reflux, and excess thyroid hormone.

I’m not suggesting that you avoid prescribed medications that are needed to treat a health condition. I would suggest that you ask your doctor or pharmacist (or research online) whether the drugs you are taking adversely affect bone density. If they do, you may want to ask your doctor about alternative approaches, and you should pay a lot more attention to the other aspects of a “bone healthy” lifestyle.

#5: Exercise is perhaps the most important aspect of a bone healthy lifestyle:Whenever our muscles pull on a bone it stimulates the bone to get stronger. I’ll put the benefits of exercise in perspective in the next section.

Exercise Is A Critical Part of  Preventing Osteoporosis

Instead of just quoting more boring studies, I’m going to share a couple of stories that help put the importance of exercise into perspective.

The first is my wife’s story. She ate a very healthy diet with minimal meat and lots of fruits and vegetables for years. She took calcium supplements on a daily basis. She walked 5 miles per day and took yoga classes several days each week. Yet when her doctor recommended a bone density scan in her early sixties she discovered she had low bone density. She was in danger of becoming osteoporotic!

weight lifting exerciseHer doctor prescribed Fosamax. My wife tried it for one day and decided the side effects were worse than the disease. So she started asking holistic health practitioners what she should do. They recommended she find a personal trainer and start pumping iron. That was not an easy solution, but it was the right one. When she went in for her second bone scan 3 months later, her doctor excitedly announced that her bone density had increased by 7%. Her doctor said “We never get results that good with Fosamax”. When my wife told her she wasn’t taking Fosamax, her doctor became even more excited. (Most doctors actually do prefer holistic approaches. They just don’t recommend them.)

The moral of this story is that you can be doing everything else right, but if you’re not doing weight bearing exercises – if you’re not pumping iron, everything else you are doing may be for naught. Weight bearing exercise is an absolutely essential part of a “bone healthy” lifestyle!

But, can exercise do it alone? Some people seem to think so. That brings up my second story. About 30 years ago one of my  UNC colleagues, who was an expert on calcium metabolism, was doing a bone density study on female athletes at UNC. One of the tennis players was nicknamed “Tab.”   Tab was a popular soft drink at that time, and Tab was all she drank – no milk, no water, only Tab. When my colleague measured the bone density of her playing arm, it was normal for a woman of her age. When he measured the bone density of her non-playing arm, it was that of a 65 year old woman. The reason is simple. When we exercise a particular bone, our body will add calcium to that bone to make it stronger. If we are not getting enough calcium from our diet, our body simply dissolves the bones elsewhere in our body to get the calcium that it needs.

The moral of this story is that exercise alone is not enough. In terms of bone health, we absolutely need exercise to take advantage of the calcium in our diet, and we absolutely need sufficient calcium in our diet to take advantage of the exercise.

This is the most glaring deficiency of the meta-analysis I described last week. None of those studies included exercise. No wonder the increase in bone density was minimal!

Putting It All Together –  A “Bone Healthy” Lifestyle

bone healthy lifestyleIf you seriously want to minimize your risk of osteoporosis, there are a few simple steps you can take (simple, but not easy).

  • Consume a “bone healthy” diet that emphasizes fresh fruits and vegetables, minimizes meats, and eliminates sodas and other acidic beverages. For more details on whether your favorite foods are acid-forming or alkaline-forming, you can find plenty of charts on the internet.
  • Minimize the use of medications that adversely affect bone density. You’ll need to work with your doctor on this one.
  • Get plenty of weight bearing exercise. This is an absolutely essential part of a bone healthy lifestyle. Your local Y can probably give you guidance if you can’t afford a personal trainer. Of course, if you have physical limitations or have a disease, you should consult with your health professional before beginning any exercise program.
  • Get your blood 25-hydroxy vitamin D level tested. If it is low, take enough supplemental vitamin D to get your 25-hydroxy vitamin D level into the sufficient range – optimal is even better. Sufficient blood levels of 25-hydroxy vitamin D are also absolutely essential for you to be able to utilize calcium efficiently.
  • Consider a calcium supplement. Even when you are doing everything else correctly, you still need adequate calcium in your diet to form strong bones. “I’m not necessarily recommending a “one-size fits all” 1,000 to 1,200 mg/day. Supplementation is always most effective when you actually need it. For example:
  • If you are not including dairy products in your diet (either because they are acid-forming or for other health reasons), it will be difficult for you to get adequate amounts of calcium in your diet. You can get calcium from other food sources such as green leafy vegetables. However, unless you plan your diet very carefully you will probably not get enough.
  • If you are taking medications that decrease bone density, that may increase your need for supplemental calcium. Unfortunately, we don’t yet have guidelines on how much is needed.
  • If you do use a calcium supplement, make sure it is complete. Don’t just settle for calcium and vitamin D. At the very least you will want your supplement to contain magnesium and vitamin K. I personally recommend that it also contain zinc, copper, and manganese.
  • Unfortunately, we don’t really have good guidelines for how much calcium you need. Studies like the one described above are challenging the old RDAs, but we don’t yet have enough studies to know how much calcium we need to build strong bones when we are following a “bone healthy” lifestyle that includes proper diet, sufficient 25-hydroxy vitamin D blood levels and plenty of exercise.

What About Medications For Preventing Bone Loss?

The danger is that, as the conclusions of this meta-analysis get widely publicized and doctors stop prescribing calcium supplements, they probably aren’t going to recommend a holistic approach. They probably won’t recommend a “bone healthy” lifestyle. Instead, they will most preventing osteoporosislikely recommend drugs to prevent bone loss. In fact, the authors of the study described last week specifically praised the use of bisphosphonate drugs (Fosamax and Zometa), and a related drug (Xgeva) that works by a similar mechanism because they increased bone density by 5-9% over 3 years.

However, these drugs have a dark side, and it’s not just the acid reflux, esophageal damage and esophageal cancer that you hear about in the TV ads. These drugs all act by blocking bone resorption, the ability of the body to break down bone. In the short term, this prevents the bone loss associated with aging and reduces the risk of bone fractures.

However, you might remember from last week’s article that bone resorption is also an essential part of bone remodeling, the process that keeps our bones young and strong. When these drugs are used for more than a few years you end up with bones that are dense, but are also old and brittle. Long term use of these drugs is associated with jaw bones that simply dissolve and bones that easily break during everyday activities. This is yet another example of drugs with side effects that look a lot like the disease you were taking the drug for in the first place.

 

The Bottom Line

  1. A recent study has reported that the RDA recommendation of 1,000 – 1,200 mg/day of calcium for people over 50 provides only a minimal increase in bone density (0.7-1.8%) over the first year or two. This translates into a very small (5-10%) decrease in risk of bone fractures. It did not matter whether the calcium came from dietary sources or from supplementation. The authors concluded that adding extra calcium to the diet, whether from foods or supplements, was not a very efficient way to increase bone density and prevent fractures.

2. This study suffers from some serious flaws, which I discussed in last week’s “Health Tips From the Professor”

3. Unfortunately, many doctors are likely to take this study to heart. They are likely to stop recommending calcium and other natural approaches and start relying even more heavily on drugs to preserve bone mass. That’s bad news because, while the most frequently proscribed drugs do increase bone mass and prevent fractures short term, they also cause your bones to age more rapidly. After a few years you end up with bones that are dense, but are also incredibly brittle and fracture very easily. That’s right. If you use these drugs long enough, they will cause the very condition you were trying to prevent.

4. We should also consider the possibility that this study may just be correct. Let’s assume for a minute that the RDA recommendation of 1,000 – 1,200 mg/day of calcium for everyone over 50 may actually be flawed advice. If so, it may finally be time to put away the “magic bullet” thinking and start seriously considering holistic approaches to preserving bone mass.

5. A far better choice is to follow a “bone healthy” lifestyle.

  • Start with a “bone healthy” diet. Avoid acid-forming foods like sodas, meats, eggs, dairy, and grains. Instead choose alkaline-forming foods like most fruits & vegetables, peas, beans, lentils, seeds and nuts.
  • Check on the medicines you are using. If they are ones that adversely affect bone density, ask your health professional if there are bone-healthier options.
  • Check your blood level of 25-hydroxy vitamin D on a regular basis. If it is low, consult with your health professional on the amount of vitamin D you need to take to bring your 25-hydroxy vitamin D into the optimal range.
  • Get plenty of weight bearing exercise. This means pumping iron. It is an absolutely essential part of a bone healthy lifestyle. Of course, if you have physical limitations or have a disease, you should consult with your health professional before beginning any exercise program.
  • If you are not getting sufficient calcium from your diet, consider a complete calcium supplement. In addition to calcium and vitamin D, a bone-healthy calcium supplement should at the very least contain magnesium and vitamin K. I also recommend it contain zinc, copper, and manganese.

Just don’t rely on a calcium supplement alone to keep your bone density where it should be. If your 25-hydroxy vitamin D isn’t where it should be and/or you aren’t doing weight bearing exercise on a regular basis, your calcium supplement may be almost useless.   All the aforementioned may aid in preventing osteoporosis.  In my opinion, that may be the biggest take-home lesson from the recent meta-analysis.

 

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure or prevent any disease.

Do Calcium Supplements Prevent Bone Fractures? – Part1

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Why The Recent Headlines May Be Misleading

Author: Dr. Stephen Chaney

 

osteoporosisDoes calcium help prevent bone fractures?  Osteoporosis is a debilitating and potentially deadly disease associated with aging. It affects 54 million Americans. It can cause debilitating back pain and bone fractures. 50% of women and 25% of men over 50 will break a bone due to osteoporosis. Hip fractures in the elderly due to osteoporosis are often a death sentence.

For that reason, the RDA for calcium has been set at 1,000 to 1,200 mg/day to reduce the risk of osteoporosis, and calcium supplements are often recommended to reach that target.However, recent headlines are proclaiming that calcium supplements do not actually prevent bone fractures and might increase your risk of a heart attack. Are the RDA recommendations wrong? Should you throw out your calcium supplements?

In this article I will review the article behind the study and help you put it into perspective. After all, you don’t really want to know whether calcium supplementation is beneficial for the average adult. You want to know whether it will be beneficial for you.

Let me start by putting the heart attack myth to rest. I have covered this in detail in a previous “Health Tips From The Professor” article, Calcium Supplements Increase Heart Attack Risk . If you don’t want to go to the trouble of reading my previous article, the short version is that:

  • Most of the studies suggesting an increased risk of heart attacks are flawed.
  • A very large study (74,000 women followed for 24 years) has shown fairly convincingly that calcium supplements do not increase heart attack risk. If anything, they decrease heart attack risk.

Unfortunately, like most other nutrition myths, this one is still being repeated – even after it has been refuted by subsequent studies.

Bone Metabolism and Osteoporosis

bone metabolism osteoporosisBefore you can truly understand osteoporosis and how to prevent it, you need to know a bit about bone metabolism. We tend to think of our bones as solid and unchanging, much like the steel girders in an office building. Nothing could be further from the truth. Our bones are dynamic organs that are in a constant change throughout our lives.

Cells called osteoclasts and osteoblasts constantly break down old bone (a process called resorption) and replace it with new bone (a process called accretion). Without this constant renewal process our bones would quickly become old and brittle (I’ll discuss more about this next week when I talk about the side effects of drugs commonly used to increase bone density).

When we are young the bone building process exceeds bone resorption and our bones grow in size and in density. During most of our adult years, bone resorption and accretion are in balance so our bone density stays constant. However, as we age bone the bone building process (accretion) slows down and we start to lose bone density. Eventually our bones look like Swiss cheese and break very easily. This is called osteoporosis.

We should also think of our bones as calcium reservoirs.  We need calcium in our bloodstream 24 hours a day for our muscles, brain, and nerves to function properly, but we only get calcium in our diet at discrete intervals. Consequently, when we eat our body tries to store as much calcium as possible in our bones. Between meals, we break down bone material so that we can release the calcium into our bloodstream that our muscle, brain & nerves need to function.

If we lead a “bone healthy” lifestyle, all of this works perfectly. We build strong bones during our growing years, maintain healthy bones during our adult years, and only lose bone density slowly as we age – maybe never experiencing osteoporosis. We always accumulate enough calcium in our bones during meals to provide for the rest of our body between meals.

What is a “bone healthy” lifestyle, you might ask. Because calcium is a major component of bone, the medical and nutrition communities have long focused on calcium as a “magic bullet” that can assure bone health. Once the importance of vitamin D was understood, it was added to the equation. For years we have been told that if we just get enough calcium and vitamin D in our diets, we would build strong bones when we were young, maintain bone density most of our adult years, and lose bone density as slowly as possible as we age.It is this paradigm that the current study challenges.

Do Calcium Supplements Prevent Bone Fractures?

prevent bone fracturesLet’s start by looking at the study behind the headlines (Tai et al, British Medical Journal, BMJ/2015; 351:h4183 doi: 10.1136/bmj.h4183). This was a meta-analysis that included 15 studies (1533 participants) looking at dietary sources of calcium and 51 studies (12,257 participants) looking at calcium supplementation in women.

The results of the meta-analysis were thought provoking, but do not exactly support the headlines you have been reading. For example:

The headlines say “Calcium Supplements Do Not Prevent Broken Bones”.

  • This study did not actually look at calcium supplementation and the risk of bone fractures. That was a previous study (Boland et al, BMJ 2015, 351:h4580) by the same authors.
  • This study showed that calcium supplementation increased bone density by 0.7-1.8%, which the authors concluded was sufficient to reduce fracture risk by about 5-10%. That’s a disappointingly small effect, but it is not zero – as the headlines suggested.

The headlines say “It’s better to get your calcium from food than from supplements”.

  • This study showed that it did not matter whether the calcium came from food or from supplements. The increase in bone density was identical.

Garbage-In, Garbage-Out

garbageMeta-analyses such as this one can be very strong, but they can also suffer from the “garbage-in, garbage-out” phenomenon. In short, if most of the studies that went into the meta-analysis were poorly designed, the conclusions of the meta-analysis will be unreliable.

The problem is that many of the individual studies were conducted 10, 20, 30 or 40 years ago when our knowledge of bone metabolism was incomplete.

  • Thirty or 40 years ago it was “state of the art” to just use a calcium supplement. Then we learned that adequate vitamin D was essential for efficient calcium utilization.
  • Most of the studies included in this meta-analysis looked at calcium supplementation without vitamin D. Only 13 of the studies (25%) included vitamin D.
  • Ten or 20 years ago it was “state of the art” to just use a calcium supplement with vitamin D. Then we learned that the blood level of 25-hydroxyvitamin D (the active form of vitamin D in the bloodstream) did not necessarily reflect vitamin D intake from the diet. In today’s world a study in which the 25-hydroxy vitamin D level is not measured should be considered sub-standard.
  • Only 18 (35%) of the studies measured baseline 25-hydroxy vitamin D levels.
  • If dietary calcium intake at baseline is already adequate, it is illogical to expect additional calcium to significantly increase bone density.
  • The baseline calcium intake was <800 mg/day (clearly inadequate) in only 26 (51%) of the studies. Baseline calcium intake was either not determined in the other studies or was already in the adequate range prior to supplementation.
  • In the future, we will probably want to include exercise as a component in the study (more about that next week). None of the studies included exercise as a component

In short, by today’s standards many, if not most, of the studies included in the meta-analysis had an inadequate design.

If I had designed the meta-analysis, I would have been a lot more restrictive in the studies I included.

  • I would have started by including only studies in which the baseline intake of calcium was <800 mg/day. If you want to critically evaluate whether calcium supplementation has a beneficial effect, you need to start with people who have an inadequate dietary intake of calcium. If their diets are already calcium sufficient, supplementation is unlikely to have any benefit.
  • At the very least I would only include studies that used calcium supplements containing 400-800 IU of vitamin D as well. In fact, based on the latest data, I would make sure that the calcium supplement I used also contained adequate levels of magnesium, vitamin K, zinc, copper and manganese. All of those have been shown to be important for bone formation and we cannot assume they are present at sufficient levels in their diet (more about that next week).
  • I would only include studies that measured blood levels of 25-hydroxy vitamin D at baseline and following supplementation with vitamin D so that we knew that the 25-hydroxy vitamin D level was sufficient to support optimal calcium utilization.
  • Finally, I would only include studies that specifically measured the effect of exercise on calcium utilization or included exercise as an integral part of their study.

The number of studies included in the meta-analysis would be much less, but they would all be high quality studies.

Finally, the authors also noted that a number of studies in the supplement group showed significantly greater (2.5 – 5.0%) increase in bone density. They dismissed them as outliers. I would have preferred a closer look at those studies to see if there was anything about the population group or study design that might explain the greater bone density increase in those studies.

Apples and Oranges

apples orangesBecause the authors included a wide variety of clinical studies, they were able to state that “Increases in bone mineral density were similar in trials of calcium monotherapy [calcium by itself] versus co-administered calcium and vitamin D…and in trials where baseline dietary calcium intake was <800 [clearly insufficient] versus >800 [probably sufficient] mg/day.” This could be considered a strength of their meta-analysis, but they are only valid comparisons if other important features of the studies being compared were uniform – i.e. they were comparing apples to apples.

But what if they were comparing apples and oranges?

For example, we know that vitamin D is required for efficient calcium utilization. When the authors compared studies having a baseline calcium intake of <800 mg/day with studies having a baseline calcium intake of >800 mg/day, they did not even check to see whether use of vitamin D was evenly distributed between the two groups. If most of the studies with a baseline calcium intake of <800 mg/day did not include vitamin D with their calcium supplements, the authors would be comparing apples and oranges. The comparison would be invalid.

Similarly, we also know that if calcium intake at baseline is adequate, adding more calcium is unlikely to increase bone density significantly. When the authors compared studies with and without vitamin D, they did not even check to see whether baseline calcium intake was evenly distributed between the two groups. If the participants in most of the studies utilizing supplements providing both calcium and vitamin D were already consuming sufficient calcium at baseline, they would be comparing apples to oranges. Again, the comparison would be invalid.

The authors of the meta-analysis simply did not provide the detail needed to determine whether their comparisons were apples to apples or apples to oranges. Thus, what seemed to be a strength of their study is actually a major weakness.

 

The Bottom Line

 

  • A recent study has reported that the RDA recommendation of 1,000 – 1,200 mg/day of calcium for people over 50 provides only a minimal increase in bone density (0.7-1.8%) over the first year or two. This translates into a very small (5-10%) decrease in risk of bone fractures. It did not matter whether the calcium came from dietary sources or from supplementation. The authors concluded that adding extra calcium to the diet, whether from food or supplements, was not a very efficient way to increase bone density and prevent fractures.
  • This study suffers from some serious flaws. It is a meta-analysis of previous clinical trials looking at the effects of calcium on bone density. Meta-analyses can be very strong studies because they average the effects of many individual studies. However, meta-analyses can also suffer from the “garbage-in, garbage-out” phenomenon. Simply put, the quality of the meta-analysis is only as good as the studies that go into it. In this case the meta-analysis included many clinical studies that were done 10, 20, 30 and even 40 years ago. Based on what we now know about bone metabolism, the design of many of those early studies was clearly inadequate (details are given in the article).

 

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure or prevent any disease.

Health Tips From The Professor