vitamin D

Which Supplements Are Good For Your Heart?

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How Should You Interpret This Study? 

Author: Dr. Stephen Chaney 

strong heartFebruary is Heart Health month. So, it is fitting that we ask, “What is the status of heart health in this country?” The American Heart Association just published an update of heart health statistics through 2019 (CW Tsao et al, Circulation, 145: e153-e639, 2022). And the statistics aren’t encouraging. [Note: The American Heart Association only reported statistics through 2019 because the COVID-19 pandemic significantly skewed the statistics in 2020 and 2021].

The Good News is that between 2009 and 2019:

  • All heart disease deaths have decreased by 25%.
  • Heart attack deaths have decreased by 6.6%.
  • Stroke deaths have decreased by 6%.

The Bad News is that:

  • Heart disease is still the leading cause of death in this country.
  • Someone dies from a heart attack every 40 seconds.
  • Someone dies from a stroke every 3 minutes.

Diet, exercise, and weight control play a major role in reducing the risk of heart disease. Best of all, they have no side effects. They represent a risk-free approach that each of us can control.

But is there something else? Could supplements play a role? Are supplements hype or hope for a healthy heart?

All the Dr. Strangeloves in the nutrition space have their favorite heart health supplements. They claim their supplements will single-handedly abolish heart disease (and help you leap tall buildings in a single bound).

On the other hand, many doctors will tell you these supplements are a waste of money. They don’t work. They just drain your wallet.

It’s so confusing. Who should you believe? Fortunately, a recent study (P An et al, Journal of the American College of Cardiology, 80: 2269-2285, 2022) has separated the hype from the hope and tells us which “heart-healthy” supplements work, and which don’t.

How Was This Study Done?

Clinical StudyThis was a major clinical study carried out by researchers from the China Agricultural University and Brown University in the US. It was a meta-analysis, which means it combined the data from many published clinical trials.

The investigators searched three major databases of clinical trials to identify:

  • 884 randomized, placebo-controlled clinical studies…
  • Of 27 types of micronutrients…
  • With a total of 883,627 patients…
  • Looking at the effectiveness of micronutrient supplementation lasting an average of 3 years on either…
    • Cardiovascular risk factors like blood pressure, total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides…or…
    • Cardiovascular outcomes such as coronary heart disease (CHD), heart attacks, strokes, and deaths due to cardiovascular disease (CVD) and all causes.

[Note: Coronary heart disease (CHD) refers to build up of plaque in the coronary arteries (the arteries leading to the heart). It is often referred to as heart disease and can lead to heart attacks (myocardial infarction). Cardiovascular disease (CVD) is a more inclusive term that includes coronary heart disease, stroke, congenital heart defects, and peripheral artery disease.]

The investigators also included an analysis of the quality of the data in each of the clinical studies and rated the evidence of each of their findings as high quality, moderate quality, or low quality.

Which Supplements Are Good For Your Heart?

The top 3 heart-healthy supplements in this study were:

Omega-3s And Heart DiseaseOmega-3 Fatty Acids:

  • Increased HDL cholesterol and decreased triglycerides, both favorable risk factors for heart health.
  • Deceased risk of heart attacks by 15%, all CHD events by 14%, and CVD deaths by 7% (see definitions of CHD and CVD above).
  • The median dose of omega-3 fatty acids in these studies was 1.8 g/day.
  • The evidence was moderate quality for all these findings.

Folic Acid:

  • Decreased LDL cholesterol (moderate quality evidence) and decreased blood pressure and total cholesterol (low quality evidence).
  • Decreased stroke risk by 16% (moderate quality evidence).

Coenzyme Q10:

  • Decreased triglycerides (high quality evidence) and reduced blood pressure (low quality evidence).
  • Decreased the risk of all-cause mortality by 32% (moderate quality evidence).
  • These studies were performed with patients diagnosed with heart failure. Coenzyme Q10 is often recommended for these patients, so the studies were likely performed to test the efficacy of this treatment.

There were three micronutrients (vitamin C, vitamin E, and vitamin D) that did not appear to affect heart disease outcomes.

Finally, as reported in previous studies, β-carotene increased the risk of stroke, CVD mortality, and all-cause mortality.

In terms of the question I asked at the beginning of this article, this study concluded that:

  • Omega-3, folic acid, and coenzyme Q10 supplements represent hope for a healthy heart.
  • Vitamin C, vitamin E, and vitamin D supplements represent hype for a healthy heart.
  • β-carotene supplements represent danger for a healthy heart.

But these conclusions just scratch the surface. To put them into perspective we need to dig a bit deeper.

How Should You Interpret This Study?

Question MarkIn evaluating the significance of these findings there are two things to keep in mind.

#1: This study is a meta-analysis and meta-analyses have both strengths and weaknesses.

The strength of meta-analyses is that by combining multiple clinical studies they can end up with a database containing 100s of thousands of subjects. This allows them to do two things:

  • It allows the meta-analysis to detect statistically significant effects that might be too small to detect in an individual study.
  • It allows the meta-analysis to detect the average effect of all the clinical studies it includes.

The weakness of meta-analyses is that the design of individual studies included in the analysis varies greatly. The individual studies vary in things like dose, duration, type of subjects included in the study, and much more.

This is why this study rated most of their conclusions as backed by moderate- or low-quality evidence. [Note: The fact that the authors evaluated the quality of evidence is a strength of this study. Most meta-analyses just report their conclusions without telling you how strong the evidence behind those conclusions is.]

#2: Most clinical studies of supplements (including those included in this meta-analysis) have two significant weaknesses.

  • Most studies do not measure the nutritional status of their subjects prior to adding the supplement. If their nutritional status for a particular nutrient was already optimal, there is no reason to expect more of that nutrient to provide any benefit.
  • Most studies measure the effect of a supplement on a cross-section of the population without asking who would be most likely to benefit.

You would almost never design a clinical study that way if you were evaluating the effectiveness of a potential drug. So, why would you design clinical studies of supplements that way?

With these considerations in mind, let me provide some perspective on the conclusions of this study.

Coenzyme Q10:

This meta-analysis found that coenzyme Q10 significantly reduced all-cause mortality in patients with heart failure. This is consistent with multiple clinical studies and a recent Cochrane Collaboration review.

Does coenzyme Q10 have any heart health benefits for people without congestive heart failure? There is no direct evidence that it does, but let me offer an analogy with statin drugs.

Statin drugs are very effective at reducing heart attacks in high-risk patients. But they have no detectable effect on heart attacks in low-risk patients. However, this has not stopped the medical profession from recommending statins for millions of low-risk patients. The rationale is that if they are so clearly beneficial in high-risk patients, they are “probably” beneficial in low-risk patients.

I would argue a similar rationale should apply to supplements like coenzyme Q10.

Omega-3s:

This study found that omega-3 reduced both heart attacks and the risk of dying from heart disease. Most previous meta-analyses of omega-3s and heart disease have come to the same conclusion. However, some meta-analyses have failed to find any heart health benefits of omega-3s. Unfortunately, this has allowed both proponents and opponents of omega-3 use for heart health to quote studies supporting their viewpoint.

However, there is one meta-analysis that stands out from all the others. A group of 17 scientists from across the globe collaborated in developing a “best practices” experimental design protocol for assessing the effect of omega-3 supplementation on heart health. They conducted their clinical studies independently, and when their data (from 42,000 subjects) were pooled, the results showed that omega-3 supplementation decreased:

  • Premature death from all causes by 16%.
  • Premature death from heart disease by 19%.
  • Premature death from cancer by 15%.
  • Premature death from causes other than heart disease and cancer by 18%.

This study eliminates the limitations of previous meta-analyses. That makes it much stronger than the other meta-analyses. And these results are consistent with the current meta-analysis.

Omega-3s have long been recognized as essential nutrients. It is past time to set Daily Value (DV) recommendations for omega-3s. Based on the recommendations of other experts in the field, I think the DV should be set at 500-1,000 mg/day. I take more than that, but this would represent a good minimum recommendation for heart health.

folic acidFolic acid:

As with omega-3s, this meta-analysis reported a positive effect of folic acid on heart health. But many other studies have come up empty. Why is that?

It may be because, between food fortification and multivitamin use, many Americans already have sufficient blood levels of folic acid. For example, one study reported that 70% of the subjects in their study had optimal levels of folates in their blood. And that study also reported:

  • Subjects with adequate levels of folates in their blood received no additional benefit from folic acid supplementation.
  • However, for subjects with inadequate blood folate levels, folic acid supplementation decreased their risk of heart disease by ~15%.

We see this pattern over and over in supplement studies. Supplement opponents interpret these studies as showing that supplements are worthless. But a better interpretation is that supplements benefit those who need them.

The problem is that we don’t know our blood levels of essential nutrients. We don’t know which nutrients we need, and which we don’t. That’s why I like to think of supplements as “insurance” against the effects of an imperfect diet.

Vitamins E and D:

The situation with vitamins E and D is similar. This meta-analysis found no heart health benefit of either vitamin E or D. That is because the clinical studies included in the meta-analysis asked whether vitamin E or vitamin D improved heart health for everyone in the study.

Previous studies focusing on patients with low blood levels of these nutrients and/or at high risk of heart disease have shown some benefits of both vitamins at reducing heart disease risk.

So, for folic acid, vitamin E, and vitamin D (and possibly vitamin C) the take-home message should be:

  • Ignore all the Dr. Strangeloves telling you that these vitamins are “magic bullets” that will dramatically reduce your risk of heart disease.
  • Ignore the naysayers who tell you they are worthless.
  • Use supplementation wisely to make sure you have the recommended intake of these and other essential nutrients.

β-carotene:

This meta-analysis reported that β-carotene increased the risk of heart disease. This is not a new finding. Multiple previous studies have come to the same conclusion.

And we know why this is. There are many naturally occurring carotenoids, and they each have unique heart health benefits. A high dose β-carotene supplement interferes with the absorption of the other carotenoids. You are creating a deficiency of other heart-healthy carotenoids.

If you are not getting lots of colorful fruits and vegetables from your diet, my recommendation is to choose a supplement with all the naturally occurring carotenoids in balance – not a pure β-carotene supplement.

The Bottom Line 

The Dr. Strangeloves in the nutrition space all have their favorite heart health supplements. They claim their supplements will single-handedly abolish heart disease (and help you leap tall buildings in a single bound).

On the other hand, many doctors will tell you these supplements are a waste of money. They don’t work. They just drain your wallet.

It’s so confusing. Who should you believe? Fortunately, a recent study has separated the hype from the hope and tells us which “heart-healthy” supplements work, and which don’t.

This study was a meta-analysis of 884 clinical studies with 883,627 participants. It reported:

  • Omega-3 supplementation deceased risk of heart attacks by 15% and all cardiovascular deaths by 7%.
  • Folic acid supplementation decreased stroke risk by 16%.
  • Coenzyme Q10 supplementation decreased the risk of all-cause mortality in patients with heart failure by 32%.
  • Vitamin C, vitamin E, vitamin D did not appear to affect heart disease outcomes.
  • β-carotene increased the risk of stroke, CVD mortality, and all-cause mortality.

For more details on this study and what it means for you, read the article above.

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 D And ADHD

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Can ADHD Be Prevented?

Author: Dr. Stephen Chaney 

vitamin dIf you are pregnant, or of childbearing age, should you be supplementing with vitamin D? Increasingly, the answer appears to be yes.

  1. Based on blood 25-hydroxy vitamin D levels (considered the most accurate marker of vitamin D status):
    • 8-11% of pregnant women in the US are deficient in vitamin D (<30 nmol/L).
    • 25% of pregnant women have insufficient vitamin D status (30-49 nmol/L).

In short, that means around 1/3 of pregnant women in the US have insufficient or deficient levels of vitamin D. The effect of inadequate vitamin D during pregnancy is not just an academic question.

2) The Cochrane Collaboration (considered the gold standard for evidence-based medicine) has recently concluded that supplementation with vitamin D reduces the risk of significant complications during pregnancy.

3) Another recent study found that inadequate vitamin D status during pregnancy delayed several neurodevelopmental milestones in early childhood, including gross motor skills, fine motor skills, and social development.

If neurodevelopmental milestones are affected, what about ADHD? Here the evidence is not as clear. Some studies have concluded that vitamin D deficiency during pregnancy increases the risk of ADHD in the offspring. Other studies have concluded there is no effect of vitamin D deficiency on ADHD.

Why the discrepancy between studies?

  • Most of the previous studies have been small. Simply put, there were too few children in the study to make statistically reliable conclusions.
  • Most of the studies measured maternal 25-hydroxyvitamin D levels in the third trimester or in chord blood at birth. However, it is during early pregnancy that critical steps in the development of the nervous system take place.

Thus, there is a critical need for larger studies that measure maternal vitamin D status in the first trimester of pregnancy. This study (M Sucksdorff et al, Journal of the American Academy of Child & Adolescent Psychiatry, 60: 142-151, 2021) was designed to fill that need.

How Was The Study Done?

Clinical StudyThis study compared 1,067 Finnish children born between 1998 and 1999 who were subsequently diagnosed with ADHD and 1,067 matched controls without ADHD. There were several reasons for choosing this experimental group.

  • Finland is among the northernmost European countries, so sun exposure during the winter is significantly less than for the United States and most other European countries. This time period also preceded the universal supplementation with vitamin D for pregnant women that was instituted in 2004.

Consequently, maternal 25-hydroxyvitamin D levels were significantly lower than in most other countries. This means that a significant percentage of pregnant women were deficient in vitamin D, something not seen in most other studies. For example:

  • 49% of pregnant women in Finland were deficient in vitamin D (25-hydoxyvitamin D <30 nmol/L) compared to 8-11% in the United States.
  • 33% of pregnant women in Finland had insufficient vitamin D status (25-hydroxyvitamin D 30-49.9 nmol/L) compared to 25% in the United States.
  • Finland, like many European countries, keeps detailed health records on its citizens. For example:
    • The Finnish Prenatal Study collected data, including maternal 25-hydroxyvitamin D levels during the first trimester), for all live births between 1991 and 2005.
    • The Care Register for Health Care recorded, among other things, all diagnoses of ADHD through 2011.

Thus, this study avoided the limitations of earlier studies. It was ideally positioned to compare maternal 25-hydroxyvitamin D levels during the first trimester of pregnancy with a subsequent diagnosis of ADHD in the offspring. The long-term follow-up was important to this study because the average age of ADHD diagnosis was 7 years (range = 2-14 years).

Vitamin D And ADHD 

Child With ADHDDoes maternal vitamin D affect ADHD in the offspring? The answer to this question appears to be a clear, yes.

If you divide maternal vitamin D levels into quintiles:

  • Offspring of mothers in the lowest vitamin D quintile (25-hydroxyvitamin D of 7.5-21.9 nmol/L) were 53% more likely to develop ADHD than offspring of mothers in the highest vitamin D quintile (49.5-132.5 nmol/L).

When you divide maternal vitamin D levels by the standard designations of deficient (<30 nmol/L), insufficient (30-49.9 nmol/L), and sufficient (≥50 nmol/L):

  • Offspring of mothers who were deficient in vitamin D were 34% more likely to develop ADHD than children of mothers with sufficient vitamin D status.

The authors concluded: “This is the first population-based study to demonstrate an association between low maternal vitamin D during the first trimester of pregnancy and an elevated risk for ADHD diagnosis in offspring. If these findings are replicated, they may have public health implications for vitamin D supplementation and perhaps changing lifestyle behaviors during pregnancy to ensure optimal maternal vitamin D levels.”

Can ADHD Be Prevented? 

Child Raising HandI realize that this is an emotionally charged title. If you have a child with ADHD, the last thing I want is for you to feel guilty about something you may not have done. So, let me start by acknowledging that there are genetic and environmental risk factors for ADHD that you cannot control. That means you could have done everything right during pregnancy and still have a child who develops ADHD.

Having said that, let’s examine things that can be done to reduce the risk of giving birth to a child who will develop ADHD, starting with vitamin D. There are two aspects of this study that are important to keep in mind.

#1: The increased risk of giving birth to a child who develops ADHD was only seen for women who were vitamin D deficient. While vitamin D deficiency is only found in 8-11% of pregnant mothers in the United States, that is an average number. It is more useful to ask who is most likely to be vitamin D deficient in this country. For example:

  • Fatty fish and vitamin D-fortified dairy products are the most important food sources of vitamin D. Fatty fish are not everyone’s favorite and may be too expensive for those on a tight budget. Many people are lactose intolerant or avoid milk for other reasons. If you are not eating these foods, you may not be getting enough vitamin D from your diet. This is particularly true for vegans.
  • If you have darker colored skin, you may have trouble making enough vitamin D from sunlight. If you are also lactose intolerant, you are in double trouble with respect to vitamin D sufficiency.
  • Obesity affects the distribution of vitamin D in the body. So, if you are overweight, you may have low 25-hydroxyvitamin D levels in your blood.
  • The vitamin D RDA for pregnant and lactating women is 600 IU, but many multivitamin and prenatal supplements only provide 400 IU. If you are pregnant or of childbearing age, it is a good idea to look for a multivitamin or prenatal supplement that provides at least 600 IU, especially if you are in one of the high risk groups listed above.
  • Some experts recommend 2,000 to 4,000 IU of supplemental vitamin D. I would not recommend exceeding that amount without discussing it with your health care provider first.
  • Finally, for reasons we do not understand, some people have a difficult time converting vitamin D to the active 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D in their bodies. If you are pregnant or of childbearing age, it is a good idea to have your blood 25-hydroxyvitamin D levels determined and discuss with your health care provider how much vitamin D you should be taking. Many people need more than 600 IU to reach vitamin D sufficiency status.

#2: Maternal vitamin D deficiency has a relatively small effect (34%) on the risk of the offspring developing ADHD. That means assuring adequate vitamin D status during pregnancy should be part of a holistic approach for reducing ADHD risk. Other factors to consider are:No Fast Food

  • Low maternal folate and omega-3 status.
  • Smoking, drug, and alcohol use.
  • Obesity.
  • Sodas and highly processed foods.

Alone, each of these factors has a small and uncertain influence on the risk of your child developing ADHD. Together, they may play a significant role in determining your child’s risk of developing ADHD.

In closing, there are three take-home lessons I want to leave you with:

  1. The first is that there is no “magic bullet”. There is no single action you can take during pregnancy that will dramatically reduce your risk of giving birth to a child who will develop ADHD. Improving your vitamin D, folate, and omega-3 status; avoiding cigarettes, drugs, and alcohol; achieving a healthy weight; and eating a healthy diet are all part of a holistic approach for reducing the risk of your child developing ADHD.

2) The second is that we should not think of these actions solely in terms of reducing ADHD risk. Each of these actions will lead to a healthier pregnancy and a healthier child in many other ways.

3) Finally, if you have a child with ADHD and would like to reduce the symptoms without drugs, I recommend this article.

The Bottom Line 

A recent study looked at the correlation between maternal vitamin D status during the first trimester of pregnancy and the risk of ADHD in the offspring. The study found:

  • Offspring of mothers who were deficient in vitamin D were 34% more likely to develop ADHD than children of mothers with sufficient vitamin D status.

The authors concluded: “This is the first population-based study to demonstrate an association between low maternal vitamin D during the first trimester of pregnancy and an elevated risk for ADHD diagnosis in offspring. If these findings are replicated, they may have public health implications for vitamin D supplementation and perhaps changing lifestyle behaviors during pregnancy to ensure optimal maternal vitamin D levels.”

In the article above I discuss what this study means for you and other factors that increase the risk of giving birth to a child who will develop ADHD.

For more details read the article above.

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.

 

Does Low Vitamin D Make You Weak?

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Why Is Vitamin D Research So Controversial?

Author: Dr. Stephen Chaney

vitamin dMillions of Americans lose muscle strength as they age, something called sarcopenia. This is not a trivial matter. Loss of muscle mass:

  • Leads to loss of mobility. It can also make it difficult to do simple things like lifting your grandchild or carrying a bag of groceries.
  • Increases your risk of falling. This often leads to serious fracture which increases your of dying prematurely. In fact, bone fractures increase your risk of dying by 3-fold or more. Even in those who recover their mobility and quality of life may never be the same.
  • Lowers your metabolic rate. This increases your risk of obesity and all the diseases that are associated with obesity.

Loss of muscle strength as we age is preventable. There are several things we can do to preserve muscle strength as we age, but in today’s article I will focus on the effect of vitamin D on muscle strength.

What if something as simple as preventing vitamin D deficiency could improve muscle strength as we age? That idea has been around for a decade or more. But, for reasons I will detail below, it has proven controversial. Let me start by sharing a recent study on vitamin D and muscle strength (N Aspell et al, Clinical Investigations in Ageing, volume 2019:14, pages 1751-1761).

How Was The Study Done?

Clinical StudyThe data for this study came from 4157 adults who were enrolled in the English Longitudinal Study On Aging. Participants in this study were all over the age of 60 and were still living in their own homes. The general characteristics of the study population were:

  • Their average age was 69.8 with 45% male and 55% female.
  • While 76% of the participants rated their health as “good” or above
    • 73% were overweight or obese.
    • 54% had a longstanding disease that limited mobility.
    • 29% were taking multiple medications.

Serum 25-hydroxy vitamin D levels were determined as a measure of vitamin D status.

  • 22% of the participants were vitamin D deficient (<30 nmol/L 25-hydroxy vitamin D).
  • 34% of the participants were vitamin D insufficient (between 30 and 50 nmol/L 25-hydroxy vitamin D).
  • 46% of the participants had adequate vitamin D status (>50 nmol/L 25-hydroxy vitamin D).

Muscle strength was assessed by a handgrip strength test with the dominant hand. Muscle performance was assessed with something called the short physical performance battery (SPPB), consisting of a walking speed test, a repeated chair raise test, and a balance test.

Does Low Vitamin D Make You Weak?

When the data on handgrip strength were analyzed:

  • Only 22% of the participants who had adequate vitamin D status had low handgrip strength.
  • 40% of participants who were vitamin D deficient had low handgrip strength. That’s almost a 2-fold difference.
  • Handgrip strength increased linearly with vitamin D status.
    • The relationship between vitamin D status and handgrip strength was highly significant (p<001).
    • The beneficial effect of vitamin D status on handgrip strength plateaued at around 55-69 nmol/L 25-hydroxy vitamin D. In other words, you need adequate vitamin D status to support muscle strength, but higher levels provide no additional benefit.

When the data on muscle performance (the SPPB test) were analyzed:

  • Only 8% of the participants who had adequate vitamin D status scored low on this test.
  • 25% of participants who were vitamin D deficient scored low on this test. That’s a 3-fold difference.
  • Muscle performance also increased linearly with vitamin D status.
    • The relationship between vitamin D status and muscle performance was also highly significant (p<001).
    • The beneficial effect of vitamin D status on muscle performance also plateaued at around 55-69 nmol/L 25-hydroxy vitamin D.

The authors concluded: “Vitamin D deficiency was associated with impaired muscle strength and performance in a large study of community-dwelling older people. It is generally accepted that vitamin D deficiency should be reversed to prevent bone disease. This strategy may also protect skeletal muscle function in aging.”

Why Is Vitamin D Research So Controversial?

ArgumentYou can be forgiven if you are saying to yourself: “I’ve heard this sort of thing before. I see a blog or headline claiming that vitamin D has a certain benefit, but it’s usually followed by later headlines saying those claims are false. Why can’t the experts agree? Is all vitamin D research bogus?”

The relationship between vitamin D status and muscle strength is no different.

  • Many, but not all, studies looking at the association between vitamin D status and muscle strength find that vitamin D status affects muscle strength.
  • However, many randomized, placebo-controlled clinical trials looking at the effect of vitamin D supplementation on muscle strength have come up empty.

A meta-analysis (L Rejnmark, Therapeutic Advances in Chronic Disease, 2: 25-37, 2011) of randomized, placebo-controlled clinical trials of vitamin D supplementation and muscle strength provides insight as to why so many of them come up empty.

The meta-analysis combined data from 16 clinical trials. The conclusions were similar to what other meta-analyses have found:

  • Seven of the studies showed a benefit of vitamin D supplementation on muscle strength. Nine did not.
  • When the data from all 16 studies were combined, there was only a slight beneficial effect of vitamin D supplementation on muscle strength.

However, it was in the discussion that the reason for these discrepancies became apparent. There were three major deficiencies in study design that were responsible for the discrepancies.

1) There was a huge difference in study design.

  • The subjects were of different ages, genders, and ethnicity.
  • The dose of vitamin D supplementation varied.
  • Different measures of muscle strength and performance were used.

Until the scientific and medical community agree on a standardized study design it will be difficult to obtain consistent results.Garbage In Garbage Out

While this deficiency explains the variation in outcomes from study to study, there are two other deficiencies in study design that explain why many of the studies failed to find an effect of vitamin D on muscle strength. I call this “Garbage In, Garbage Out”. Simply put, if the study has design flaws, it may be incapable of detecting a positive effect of vitamin D on muscle strength.

2) Many of the studies did not measure vitamin D status of the participants at the beginning of the study.

  • The results of the study described above show that additional vitamin D will be of little benefit for anyone who starts the study with an adequate vitamin D status.
  • In the study above 46% of the participants had adequate vitamin D status. This is typical for the elderly community. When almost 50% of the participants in a study have adequate vitamin D status at the beginning of a study it becomes almost impossible to demonstrate a beneficial effect of vitamin D supplementation on any outcome.

It is essential that future studies of vitamin D supplementation focus on participants who have low vitamin D status. Otherwise, you are almost guaranteeing a negative outcome.

3) Most of the studies ignored the fact that vitamin D status is only one of three factors that are essential for muscle strength.

  • In the case of muscle strength, especially in the elderly, the three essentials are vitamin D, protein, and exercise. All three are needed to maintain or increase muscle strength. Simply put, if one is missing, the other two will have little or no effect on muscle strength. Unfortunately, you cannot assume that exercise and protein intake are adequate in older Americans:
  • Many older adults don’t get enough exercise because of physical limitations.

Unfortunately, many clinical studies on the effect of vitamin D supplementation and muscle strength fail to include exercise and adequate protein intake in the study. Such clinical trials are doomed to failure.

Now you know why vitamin D research is so controversial. Until the scientific and medical community get their act together and perform better designed experiments, vitamin D research will continue to be controversial and confusing.

What Does This Mean For You?

Old Man Lifting WeightsLoss of muscle mass as we age is not a trivial matter. As described above, it:

  • Leads to loss of mobility.
  • Increases your risk of falling. This often leads to serious fractures which increase your risk of disability and death.
  • Lowers your metabolic rate, which increases your risk of obesity and obesity-related diseases.

So, what can you do prevent loss of muscle mass as you age? The answer is simple:

  • Aim for 25-30 grams of high-quality protein in each meal.
    • That protein can come from meat, fish, eggs, or vegetable sources such as beans, nuts, and seeds.
    • That doesn’t mean you need to consume an 8-ounce steak or a half chicken. 3-4 ounces is plenty.
    • However, it does mean you can’t subsist on green salads and leafy greens alone. They are healthy, but you need to include a good protein source if you are going to meet your protein needs.
  • Aim for 150 minutes of moderate intensity exercise per week.
    • At least half of that exercise should be resistance exercise (lifting weights, for example).
    • If you have physical limitations, consult your doctor and work with a physical therapist or personal trainer to design resistance exercises you can do.
    • Aim for a variety of resistance exercises. You will only strengthen the muscles you exercise.
  • Aim for an adequate vitamin D status.
    • Start with a multivitamin containing at least 800 IU of vitamin D3.
    • Because there is large variation in the efficiency with which we convert vitamin D to 25-hydroxy vitamin D, you should get your serum 25-hydroxyvitamin D tested on a yearly basis. Your health professional can tell you if you need to take larger amounts of vitamin D3.
    • This study suggests that a serum 25-hydroxy vitamin D level of 55-69 nmol/L is optimal, and higher levels provide no additional benefit. That means there is no need to take mega-doses of vitamin D3 unless directed by your health professional.

The Bottom Line 

A recent study looked at the effect of vitamin D status on muscle strength and performance in a healthy population with an average age of 69.

When they looked at handgrip strength:

  • Only 22% of the participants with an adequate vitamin D status had low handgrip strength.
  • 40% of participants who were vitamin D deficient had low handgrip strength. That’s almost a 2-fold difference.
  • Handgrip strength increased linearly with vitamin D status.

When they looked at muscle performance:

  • Only 8% of the participants with an adequate vitamin D status scored low on this test.
  • 25% of participants who were vitamin D deficient scored low on this test. That’s a 3-fold difference.
  • Muscle performance also increased linearly with vitamin D status.

The authors concluded: “Vitamin D deficiency was associated with impaired muscle strength and performance in a large study of community-dwelling older people. It is generally accepted that vitamin D deficiency should be reversed to prevent bone disease. This strategy may also protect skeletal muscle function in aging.”

If we look at the research more broadly, there are three factors that are essential for maintaining muscle mass as we age: exercise, protein, and vitamin D. Therefore, my recommendations are to:

1)  Aim for 25-30 grams of high-quality protein in each meal.

2) Aim for 150 minutes of moderate intensity exercise per week. At least half of that exercise should be resistance exercise.

3) Aim for an adequate vitamin D status (>50 nmol/L of serum 25-hydroxy vitamin D). A good place to start is with a multivitamin providing at least 800 IU of vitamin D3.

For more details on my recommendations and a discussion of why studies on vitamin D supplementation are often confusing, read the article above.

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 Vegans Have Strong Bones?

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When Is Supplementation Important? 

Author: Dr. Stephen Chaney

Healthy BoneWhole food, vegan diets are incredibly healthy.

  • They have a low caloric density, which can help you maintain a healthy weight.
  • They are anti-inflammatory, which can help prevent all the “itis” diseases.
  • They are associated with reduced risk of diabetes, heart disease, and some cancers.
  • Plus a recent study has shown that vegans age 60 and older require 58% fewer medications than people consuming non-vegetarian diets.

But vegan diets are incomplete, and as I have said previously, “We have 5 food groups for a reason”. Vegan diets tend to be low in several important nutrients, but for the purposes of this article I will focus on calcium and vitamin D. Vitamin D is a particular problem for vegans because mushrooms are the only plant food that naturally contain vitamin D, and the vitamin D found in mushrooms is in the less potent D2 form.

Calcium and vitamin D are essential for strong bones, so it is not surprising that vegans tend to have less dense bones than non-vegans. But are these differences significant? Are vegans more likely to have broken bones than non-vegans?

That is the question the current study (DL Thorpe et al, American Journal of Clinical Nutrition, 114: 488-495, 2021) was designed to answer. The study also asked whether supplementation with calcium and vitamin D was sufficient to reduce the risk of bone fracture in vegans.

How Was This Study Done?

Clinical StudyThe data for this study were obtained from the Adventist Health Study-2. This is a study of ~96,000 members of the Seventh-day Adventist Church in North America who were recruited into the study between 2002 and 2007 and followed for up to 15 years.

Seventh-day Adventists are a good group for this kind of study because the Adventist church advocates a vegan diet consisting of legumes, whole grains, nuts, fruits, and vegetables. However, it allows personal choice, so a significant number of Adventists choose modifications of the vegan diet and 42% of them eat a nonvegetarian diet.

This diversity allows studies of the Adventist population to not only compare a vegan diet to a nonvegetarian diet, but also to compare it with the various forms of vegetarian diets.

This study was designed to determine whether vegans had a higher risk of hip fractures than non-vegan Adventists. It was performed with a sub-population of the original study group who were over 45 years old at the time of enrollment and who were white, non-Hispanic. The decision to focus on the white non-Hispanic group was made because this is the group with the highest risk of hip fractures after age 45.

At enrollment into the study all participants completed a comprehensive lifestyle questionnaire which included a detail food frequency questionnaire. Based on the food frequency questionnaire participants were divided into 5 dietary patterns.

  • Vegans (consume only a plant-based diet).
  • Lacto-ovo-vegetarian (include dairy and eggs in their diet).
  • Pesco-vegetarians (include fish as well as dairy and eggs in their diet).
  • Semi-vegetarians (include fish and some non-fish meat (primarily poultry) as well as dairy and eggs in their diet).
  • Non-vegetarians (include all meats, dairy, and eggs in their diet). Their diet included 58% plant protein, which is much higher than the typical American diet, but much less than the 96% plant protein consumed by vegans.

Every two years the participants were mailed follow-up questionnaires that included the question, “Have you had any fractures (broken bones) of the wrist or hip after 2001? Include only those that came from a fall or minor accident.”

Can Vegans Have Strong Bones?

Unhealthy BoneThe results of this study were striking.

  • When men and women were considered together there was an increasing risk of hip fracture with increasing plant-based diet patterns. But the differences were not statistically significant.
  • However, the effect of diet pattern on the risk of hip fractures was strongly influenced by gender.
    • For men there was no association between diet pattern and risk of hip fractures.
    • For women there was an increased risk of hip fractures across the diet continuum from nonvegetarians to vegans, with vegan women having a 55% higher risk of hip fracture than nonvegetarian women.
  • The increased risk of hip fractures in vegan women did not appear to be due to other lifestyle differences between vegan women and nonvegetarian women. For example:
    • Vegan women were almost twice as likely to walk more than 5 miles/week than nonvegetarian women.
    • Vegan women consumed more vitamin C and magnesium, which are also important for strong bones, than nonvegetarian women.
    • Vegan women got the same amount of daily sun exposure as nonvegetarian women.
  • The effect of diet pattern on the risk of hip fractures was also strongly influenced by supplementation with Calcium Supplementcalcium and vitamin D.
    • Vegan women who did not supplement with calcium and vitamin D had a 3-fold higher risk of hip fracture than nonvegetarian women who did not supplement.
    • Vegan women who supplemented with calcium and vitamin D (660 mg/day of calcium and 13.5 mcg/day of vitamin D on average) had no increased risk of hip fracture compared to nonvegetarian women who supplemented with calcium and vitamin D.
  • In interpreting this study there are a few things we should note.
    • The authors attributed the lack of an effect of a vegan diet on hip fracture risk in men to anatomical and hormonal differences that result in higher bone density for males.
    • In addition, because the average age of onset of osteoporosis is 15 years later for men than for women, this study may not have been adequately designed to measure the effect of a vegan diet on hip fracture in men. Ideally, the study should have enrolled participants who were at least 60 or older if it wished to detect an effect of diet on hip fractures in men.
    • Finally, because the study enrolled only white, non-Hispanic women into the study, it does not tell us the effect of a vegan diet on women of other ethnicities. Once again, if there is an effect, it would likely occur at an older age than for white, non-Hispanic women.

The authors concluded, “Without combined supplementation of both vitamin D and calcium, female vegans are at high risk of hip fracture. However, with supplementation the excessive risk associated with vegans disappeared.”

Simply put, vegan diets are very healthy. They reduce the risk of heart disease, high blood pressure, diabetes, some cancers, and inflammatory diseases.

However, the bad news is:

  • Vegan women have a lower intake of both calcium and vitamin D than nonvegetarian women.
  • Vegan women have lower bone density than nonvegetarian women.
  • Vegan women have a higher risk of hip fracture than nonvegetarian women.

The good news is:

  • Supplement with calcium and vitamin D eliminates the increased risk of hip fracture for vegan women compared to nonvegetarian women.

When Is Supplementation Important?

Supplementation PerspectiveMuch of the controversy about supplementation comes from a “one size fits all” mentality. Supplement proponents are constantly proclaiming that everyone needs nutrient “X”. And scientists are constantly proving that everyone doesn’t need nutrient “X”. No wonder you are confused.

I believe in a more holistic approach for determining whether certain supplements are right for you. Dietary insufficiencies, increased need, genetic predisposition, and diseases all affect your need for supplementation, as illustrated in the diagram on your left. I have discussed this approach in more detail in a previous issue (https://chaneyhealth.com/healthtips/do-you-need-supplements/) of “Health Tips From the Professor”.

But today I will just focus on dietary insufficiencies.

  • Most Americans consume too much highly processed fast and convenience foods. According to the USDA, we are often getting inadequate amounts of calcium, magnesium, and vitamins A, D, E and C. Iron is also considered a nutrient of concern for young children and pregnant women.
  • According to a recent study, regular use of a multivitamin is sufficient to eliminate most these deficiencies except for calcium, magnesium, and vitamin D. A well-designed calcium, magnesium and vitamin D supplement may be needed to eliminate those deficiencies.
  • In addition, intake of omega-3 fatty acids from foods appears to be inadequate in this country. Recent studies have found that American’s blood levels of omega-3s are among the lowest in the world and only half of the recommended level for reducing the risk of heart disease. Therefore, omega-3 supplementation is often a good idea.

Ironically, “healthy” diets are not much better when it comes to dietary insufficiencies. That is because many of these diets eliminate one or more food groups. And, as I have said previously, we have 5 food groups for a reason.

Take the vegan diet, for example:

  • There is excellent evidence that whole food, vegan diets reduce the risk of heart disease, diabetes, inflammatory diseases, and some cancers. It qualifies as an incredibly healthy diet.
  • However, vegan diets exclude dairy and meats. They are often low in protein, vitamin B12, vitamin D, calcium, iron, zinc, and long chain omega-3 fatty acids. Supplementation with these nutrients is a good idea for people following a vegan diet.
  • The study described above goes one step further. It shows that supplementation with calcium and vitamin D may be essential for reducing the risk of hip fractures in vegan women.

There are other popular diets like Paleo and keto which claim to be healthy even though there are no long-term studies to back up that claim.

  • However, those diets are also incomplete. They exclude fruits, some vegetables, grains, and most plant protein sources.
  • A recent study reported that the Paleo diet increased the risk of calcium, magnesium, iodine, thiamin, riboflavin, folate, and vitamin D deficiency. The keto diet is even more restrictive and is likely to create additional deficiencies.
  • And it is not just nutrient deficiencies that are of concern when you eliminate plant food groups. Plants also provide a variety of phytonutrients that are important for optimal health and fiber that supports the growth of beneficial gut bacteria.

In short, the typical American diet has nutrient insufficiencies. “Healthy” diets that eliminate food groups also create nutrient insufficiencies. Supplementation can fill those gaps.

The Bottom Line

Vegan diets are incredibly healthy, but:

  • They eliminate two food groups – dairy, and meat protein.
  • They have lower calcium and vitamin D intake than nonvegetarians.
  • They also have lower bone density than nonvegetarians.

The study described in this article was designed to determine whether vegans also had a higher risk of bone fractures. It found:

  • Vegan women who don’t supplement have a 3-fold higher risk of hip fracture than nonvegetarian women.
  • The increased risk of hip fractures in vegan women did not appear to be due to other lifestyle differences between vegan women and nonvegetarian women.
  • Supplementation with calcium and vitamin D (660 mg/day of calcium and 13.5 mcg/day of vitamin D on average) eliminated the difference in risk of hip fracture between vegan women and nonvegetarian women.

In the article above I discuss the importance of supplementation in assuring diets are nutritionally complete.

  • In short, the typical American diet has nutrient insufficiencies. “Healthy” diets that eliminate food groups also create nutrient insufficiencies. Supplementation can fill those gaps.

For more details about the study and a discussion of which supplements may be needed to assure nutritionally adequate diets, read the article above.

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.

Are Vegan Diets Bad For Your Bones?

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The Secrets To A Healthy Vegan Diet

Author: Dr. Stephen Chaney

Frail ElderlyOsteoporosis 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.

As I discussed in a previous issue of “Health Tips From The Professor”, a “bone-healthy lifestyle requires 3 essentials – calcium, vitamin D, and weight bearing exercise. If any of these three essentials is presence in inadequate amounts, you can’t build healthy bones. In addition, other nutrients such as protein, magnesium, zinc, vitamin B12, and omega-3 fatty acids may play supporting roles.

Vegan and other plant-based diets are thought to be very healthy. They decrease the risk of heart disease, diabetes, and some cancers. However, vegan diets tend to be low in calcium, vitamin D, zinc, vitamin B12, protein, and omega-3 fatty acids. Could vegan diets be bad for your bones?

A meta-analysis of 9 studies published in 2009 (LT Ho-Pham et al, American Journal of Clinical Nutrition 90: 943-950, 2009) reported that vegans had 4% lower bone density than omnivores, but concluded this difference was “not likely to be clinically relevant”.

However, that study did not actually compare bone fracture rates in vegans and omnivores. So, investigators have followed up with a much larger meta-analysis (I Iguacel et al, Nutrition Reviews 77, 1-18, 2019) comparing both bone density and bone fracture rates in vegans and omnivores.

How Was This Study Done?

Clinical StudyThe investigators searched the literature for all human clinical studies through November 2017 that compared bone densities and frequency of bone fractures of people consuming vegan and/or vegetarian diets with people consuming an omnivore diet.

  • Vegan diets were defined as excluding all animal foods.
  • Vegetarian diets were defined as excluding meat, poultry, fish, seafood, and flesh from any animal but including dairy foods and/or eggs. [Note: The more common name for this kind of diet is lacto-ovo vegetarian, but I will use the author’s nomenclature in this review.]
  • Omnivore diets were defined as including both plant and animal foods from every food group.

The investigators ended up with 20 studies that had a total of 37,134 participants. Of the 20 studies, 9 were conducted in Asia (Taiwan, Vietnam, India, Korea, and Hong-Kong), 6 in North America (the United States and Canada), and 4 were conducted in Europe (Italy, Finland, Slovakia, and the United Kingdom).

Are Vegan Diets Bad For Your Bones?

Here is what the investigators found:

Unhealthy BoneBone density: The clinical studies included 3 different sites for bone density measurements – the lumbar spine, the femoral neck, and the total body. When they compared bone density of vegans and vegetarians with the bone density of omnivores, here is what they found:

Lumbar spine:

    • Vegans and vegetarians combined had a 3.2% lower bone density than omnivores.
    • The effect of diet was stronger for vegans (7% decrease in bone density) than it was for vegetarians (2.3% decrease in bone density).

Femoral neck:

    • Vegans and vegetarians combined had a 3.7% lower bone density than omnivores.
    • The effect of diet was stronger for vegans (5.5% decrease in bone density) than it was for vegetarians (2.5% decrease in bone density).

Whole body:

    • Vegans and vegetarians combined had a 3.2% lower bone density than omnivores.
    • The effect of diet was statistically significant for vegans (5.9% decrease in bone density) but not for vegetarians (3.5% decrease in bone density). [Note: Statistical significance is not determined by how much bone density is decreased. It is determined by the size of the sample and the variations in bone density among individuals in the sample.]

Bone FractureBone Fractures: The decrease in bone density of vegans in this study was similar to that reported in the 2009 study I discussed above. However, rather than simply speculating about the clinical significance of this decrease in bone density, the authors of this study also measured the frequency of fractures in vegans, vegetarians, and omnivores. Here is what they found.

  • Vegans and vegetarians combined had a 32% higher risk of bone fractures than omnivores.
  • The effect of diet on risk of bone fractures was statistically significant for vegans (44% higher risk of bone fracture) but not for vegetarians (25% higher risk of bone fractures).
  • These data suggest the decreased bone density in vegans is clinically significant.

The authors concluded, “The findings of this study suggest that both vegetarian and vegan diets are associated with lower bone density compared with omnivorous diets. The effect of vegan diets on bone density is more pronounced than the effect of vegetarian diets, and vegans have a higher fracture risk than omnivores. Both vegetarian and vegan diets should be appropriate planned to avoid dietary deficiencies associated with bone health.”

The Secrets To A Healthy Vegan Diet

Emoticon-BadThe answer to this question lies in the last statement in the author’s conclusion, “Both vegetarian and vegan diets should be appropriate planned to avoid dietary deficiencies associated with bone health.” 

The problem also lies in the difference between what a nutrition expert considers a vegan diet and what the average consumer considers a vegan diet. To the average consumer a vegan diet is simply a diet without any animal foods. What could go wrong with that definition? Let me count the ways.

  1. Sugar and white flour are vegan. A vegan expert thinks of a vegan diet as a whole food diet – primarily fruits, vegetables, whole grains, beans, nuts, and seeds. A vegan novice includes all their favorites – sodas, sweets, and highly processed foods. And that may not leave much room for healthier vegan foods.

2) Big Food, Inc is not your friend. Big Food tells you that you don’t need to give up the taste of animal foods just because you are going vegan. They will just combine sugar, white flour, and a witch’s brew of chemicals to give you foods that taste just like your favorite meats and dairy foods. The problem is these are all highly processed foods. They are not healthy. Some people call them “fake meats” or “fake cheeses”. I call them “fake vegan”.

If you are going vegan, embrace your new diet. Bean burgers may not taste like Big Macs, but they are delicious. If need other delicious vegan recipe ideas, I recommend the website https://forksoverknives.com.

3) A bone healthy vegan diet is possible, but it’s not easy. Let’s go back to the author’s phrase “…vegan diets should be appropriate planned to avoid dietary deficiencies associated with bone health.” A vegan expert will do the necessary planning. A vegan novice will assume all they need to do is give up animal foods. 

As I said earlier, vegan diets tend to be low in calcium, vitamin D, zinc, vitamin B12, protein, and omega-3 fatty acids. Let’s look at how a vegan expert might plan their diet to get enough of those bone-healthy nutrients.

    • Calcium. The top plant sources of calcium are leafy greens and soy foods at about 100-250 mg (10-25% of the DV) of calcium per serving. Some beans and seeds are moderately good sources of calcium. Soy foods are a particularly good choice because they are a good source of calcium and contain phytoestrogens that stimulate bone formation.

A vegan expert makes sure they get these foods every day and often adds a calcium supplement.

    • Protein. Soy foods, beans, and some whole grains are the best plant sources of protein.soy

It drives me crazy when a vegan novice tells me they were told they can get all the protein they need from broccoli and leafy greens. That is incredibly bad advice.

A vegan expert makes sure they get soy foods, beans, and protein-rich grains every day and often adds a protein supplement.

    • Zinc. There are several plant foods that supply around 20% the DV for zinc including lentils, oatmeal, wild rice, squash and pumpkin seeds, quinoa, and black beans.

A vegan expert makes sure they get these foods every day and often adds a multivitamin supplement containing zinc.

    • Vitamin D and vitamin B12. These are very difficult to get from a vegan diet. Even vegan experts usually rely on supplements to get enough of these important nutrients.

4) Certain vegan foods can even be bad for your bones. I divide these into healthy vegan foods and unhealthy “vegan” foods. 

    • Healthy vegan foods that can be bad for your bones include.
      • Pinto beans, navy beans, and peas because they contain phytates.
      • Raw spinach & swiss chard because they contain oxalates.
      • Both phytates and oxalates bind calcium and interfere with its absorption.
      • These foods can be part of a healthy vegan diet, but a vegan expert consumes them in moderation.
    • Unhealthy “vegan” foods that are bad for your bones include sodas, salt, sugar, and alcohol.
      • The mechanisms are complex, but these foods all tend to dissolve bone.
      • A vegan expert minimizes them in their diet.

5) You need more than diet for healthy bones. At the beginning of this article, I talked about the 3 Weight Trainingessentials for bone formation – calcium, vitamin D, and exercise. You can have the healthiest vegan diet in the world, but if you aren’t getting enough weight bearing exercise, you will have low bone density. Let me close with 3 quick thoughts:

    • None of the studies included in this meta-analysis measured how much exercise the study participants were getting.
    • The individual studies were generally carried out in industrialized countries where many people get insufficient exercise.
    • The DV for calcium in the United States is 1,000-1,200 mg/day for adults. In more agrarian societies dietary calcium intake is around 500 mg/day, and osteoporosis is almost nonexistent. What is the difference? These are people who are outside (vitamin D) doing heavy manual labor (exercise) in their farms and pastures every day.

In summary, a bone healthy vegan lifestyle isn’t easy, but it is possible if you work at it.

The Bottom Line 

A recent meta-analysis asked two important questions about vegan diets.

  1.     Do vegans have lower bone density than omnivores?

2) Is the difference in bone density clinically significant? Are vegans more likely to suffer from bone fractures?

The study found that:

  • Vegans had 5.5%–7% lower bone density than omnivores depending on where the bone density was measured.
  • Vegans were 44% more likely to suffer from bone fractures than omnivores.

The authors of the study concluded, ““The findings of this study suggest that…vegan diets are associated with lower bone density compared with omnivorous diets, and vegans have a higher fracture risk than omnivores…Vegan diets should be appropriate planned to avoid dietary deficiencies associated with bone health.”

In evaluating the results of this study, I took a detailed look at the pros and cons of vegan diets and concluded, “A bone healthy vegan lifestyle isn’t easy, but it is possible if you work at it.”

For more details about study and my recommendations for a bone healthy vegan lifestyle read the article above.

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.

Update On The “Truth About Vaccines”

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The Four Biggest Unanswered Questions

Author: Dr. Stephen Chaney

newspaper heallinesAs someone who is not normally a proponent of vaccinations, I have done my best to provide a scientifically accurate evaluation of the vaccines for COVID-19. My purpose has not been to change people’s minds.

  • If you have already decided to get vaccinated, I applaud you.
  • If you have decided not to get vaccinated, I respect your opinion.

I have written my articles for those of you who recognize the dangers of COVID-19, want to get vaccinated, but are hesitant because of all the negative chatter about the vaccines you have seen on the internet.

I believe every vaccine should be evaluated on the basis of its risks and benefits.

The benefits are clear. COVID-19 is a deadly disease. It is hard to believe that anyone could look at what has happened in the United States and around the world and not realize COVID-19 is not the common flu. It is the most infectious and deadly disease we have seen in our lifetime. Anything that can help us conquer this deadly disease is tremendously beneficial.

However, every vaccine has risks. The risks are extremely low, but they are not zero. And some past vaccines have had unexpected risks. For that reason, I have evaluated potential risks, including those “risks” you have heard about on the internet, against actual data. I have asked, “Are the risks real?”, “Are they serious?”, and “Do they occur often enough to be of concern?”

The yardstick I use for “Do they occur often enough…?” is the 1 in a million to 1 in 10 million range. The chance of dying in a plane crash is 1 in 10 million. Yet that doesn’t stop us from getting on planes to fly where we want to go.

I think that is an apt analogy. Serious risks from the COVID-19 vaccines are in the 1 in 10 million range. I am willing to take that risk because it will take us to where we want to go – the other side of this pandemic.

I summarized the risks and benefits of the COVID-19 vaccines in a recent “Health Tips From The Professor” article (https://chaneyhealth.com/healthtips/the-truth-about-vaccination/). However, science marches on. That article was written just one month ago, but it is time to update the data and also acknowledge what we still don’t know.

Update On The “Truth About Vaccines”

 

Last week I recorded a talk on the “The Truth About Vaccines”. Part of my motivation was to provide people with audio and video files that would be easier to share. However, I also used that opportunity to update the information on vaccines. Here are the files. Consider them a gift you can use to spread the word about the vaccines. 

 

Video Link: 

https://zoom.us/rec/share/WkDiDdygAnsY4-8YO9HvT55jPOOH73xZ2cTy-cIMDBWSEhOOxgrxliUoH7iAtD5l.hVMILee_-bJg0Xvd

Passcode: FUfZ$3F$ 

Audio Link:

https://zoom.us/rec/play/vIXHPtXHzg-WV8KQb7JjZws49J0z_LY2yOKA5fWIN93GKvLUw08ViOpOa9QcLlvzEphIKibSvcwhgmoV.07AjXCj2j8Ac1cQy

Passcode: FUfZ$3F$

Note: If you want to share these audio and video files or the “Health Tips From The Professor” article I wrote a month ago, share the link rather than forwarding this email to them.

Similarly, if you would like to share this article with someone, share the link given at the beginning and end of this article rather than forwarding this email to them.

This is because if you forward this email to someone who unsubscribes because they aren’t in favor of vaccinations, it will unsubscribe you from receiving future issues of “Health Tips From the Professor”.

The Four Biggest Unanswered Questions

questionsIf you feel like the experts have been “flying by the seat of their pants”, that is because we are. When COVID-19 burst on the scene and spread like wildfire, it was a completely unknown entity. We had no idea what to expect or how effective measures to control it would be.

In fact, much of what we thought we knew was plain wrong. That is why:

  • We went from “masks are only important for health care workers” to “masks only protect others” to “masks protect us” to “maybe we need double masks”.
  • That is why a state like California, which has remained mostly locked-down and a state like Florida, which has remained mostly open, have ended up with about the same per capita cases and deaths from COVID-19.

Clearly some mitigation efforts are needed to “flatten the curve” and prevent our hospitals from being overwhelmed. We cannot just let the virus run rampant. But there is no clear agreement among experts as to which mitigation efforts are essential.

So, with perhaps a little humility, let me address the four greatest unanswered questions about COVID-19 and the vaccines. In each case, I will:

  • Give you the facts as we know them.
  • Give you my opinion.
  • Tell you what to watch for and what to do about it.

Here are the questions:

#1: How Long Will Immunity Last? Most headlines you have seen recently are asking this question with strong immune systemregards to the vaccines. But this question is equally important for those of you who have recovered from COVID-19. You also want to know if and how long you are protected from getting infected again.

Studies on this important question have mostly relied on measuring antibodies to COVID-19 in the bloodstream. And the answer appears to be similar for people who have been infected with COVID-19 and people who have been vaccinated, namely:

  • There are significant individual differences.
    • In some people, antibody levels decrease after a few months.
    • In other people, antibody levels appear to remain high for at least 6-8 months.

This is why the CDC is considering recommending a booster shot of the vaccine 6-12 months after you have completed your first round of vaccinations. It is also why some are recommending you get vaccinated even if you have recovered from COVID-19. The theory is that you will need to boost your antibody levels again to maintain full immunity from COVID-19.

But is a booster shot really necessary? As I have written previously:

  • Both the Pfizer and Moderna vaccines create memory cells as well as circulating antibodies.
    • Memory cells reside in the bone marrow and retain the blueprint for making more antibody-producing cells if the virus ever reappears. They are responsible for long-term immunity.
    • For example, many of you may remember a few years ago, a new variant of the flu virus appeared that hit young people much harder than people over 50. The explanation we were given at the time was that the new variant of the virus was similar to a flu virus that had widely circulated 30 years earlier. We had retained significant immunity to the previous virus, and it protected us from the new virus as well.
  • Because of memory cells, I am optimistic that we will retain significant immunity to COVID-19 even after circulating antibody levels have disappeared. But we won’t know for sure until we have accumulated enough data to know how well the vaccines protect us from COVID-19 a year or two down the road.
  • However, the data on patients who have recovered from COVID-19 is encouraging. So far, the reinfection rate seems to be around 1-2% and most of the recurring cases are mild.

So, should you get a booster shot? The risk of the vaccines will not change, so we need to look at the benefit side of the ledger.

  • If I am right and COVID cases are low 6-12 months from now, the benefit of getting a booster shot would be small. I’d give it a pass.
  • If I am wrong and COVID comes back with a vengeance, getting a booster shot might be prudent.

#2: Do We Need To Fear The Variants? You have seen the hype, “The new variants are highly contagious, Fearand vaccines may not work against them.” The first claim is correct, but existing evidence suggests that the second claim is overblown.

  • Tests with antibodies from patients who have recovered from COVID-19 and from patients who have been vaccinated find that these antibodies are 70-90% effective at neutralizing the new variants. To put that into context, 70-90% effectiveness is significantly higher than the average flu vaccine.
  • New data coming out of England, where one of the variants originated, reports that the reinfection rate for people who have recovered from COVID-19 is around 0.7%, and this has not changed since the British variant strain appeared. [If the antibodies produced from the original COVID infection were not effective against the new variant, we would have expected reinfection rates to increase as the new variant became the predominant version of COVID circulating in the country.]

Of course, these data have not deterred the fearmongers. They are telling you that it is only a matter of time until a variant comes along that is unaffected by vaccines. I consider this unlikely, and here is why.

  • Vaccines are directed against the spike protein of the virus. That is the same protein the virus uses to bind to our cells. Any mutations severe enough to eliminate antibody binding to the spike protein are also likely to prevent the spike protein from binding to our cells. If the spike protein can’t bind to our cells, the virus can’t enter our cells. Such mutant viruses would be non-infectious. They would die out spontaneously.
  • Because of that, I am optimistic that the current vaccines will retain significant effectiveness against new variants as they arise.

Once again, the CDC may recommend a booster shot to help protect against the variants. The pharmaceutical companies are also working on vaccines that are specific to the new variants.

Should you get one of these shots? Once again, we won’t know for sure until we see how well the vaccines protect us from the new variants.

  • If I am right and COVID cases are low 6-12 months from now, the benefit of getting a shot would be small. I’d give it a pass.
  • If I am wrong and a new variant causes a massive surge in COVID cases and deaths in people who have been vaccinated, getting another shot might be prudent.

#3: Can I Get My Life Back After Vaccination? You have probably heard the CDC recommendations that we can still get COVID-19 and pass it on to others after we have been vaccinated. We should, therefore, continue to wear masks and socially distance ourselves.

I have had many people say to me, “If that’s true, why should I even bother to get vaccinated?” Let me start by covering what we know and don’t know about this question. Then I will put it into perspective for you.

  • The immune cells in the upper respiratory tract are not in perfect sync with the rest of the immune system. That means that after vaccination we may not get quite the level of protection in our upper respiratory track that we do in the rest of our body.
  • In the initial studies with rhesus monkeys, the animals were vaccinated and subsequently a high titer of live virus was sprayed directly into their noses. Virus was detected in their nasal passages for about 3 days before it disappeared.
    • The animals did not have detectable levels of virus in their bloodstreams. Nor did they develop any disease symptoms.
    • However, the brief presence of live virus in their nasal passages led to the suggestion that one might still be able to pass the virus on to others after vaccination.
  • Small, preliminary studies with a subset of patients enrolled in the vaccine clinical trials suggested that the vaccines might only be around 60% effective at preventing upper respiratory tract infections.
    • That means if you are exposed to COVID-19, you might have a 40% chance of developing an upper respiratory tract infection. In most cases you will be asymptomatic, but you could pass the virus on to others.
    • The good news is that you are still 95% protected against severe disease, hospitalization, chronic long-term symptoms, and death. This is the answer to the “Why bother?” question.
  • However, new data out of Israel gives a more optimistic assessment. The latest study reported that the Pfizer vaccine is 89% effective at preventing even asymptomatic disease.

The bottom line is that the data are still coming in. It may be another 6-12 months before we have an accurate estimate of your risk of developing asymptomatic disease and passing the virus on to someone else if you are exposed to COVID-19 after being vaccinated.

So, what do I recommend? I can’t tell you what you should do, but I will tell you what I plan to do.

  • I still plan to wear a mask and social distance when I am out and about.
  • I am comfortable meeting with small groups of close friends and family without a mask, especially if they have also been vaccinated.
  • I am comfortable going back to church because our church follows an excellent social distancing protocol.
  • I am comfortable traveling to visit our family in California.
  • Once the number of COVID-19 cases has reached a low level, I will be comfortable resuming all my previous activities, subject, of course, to any state mandates.

News Flash: Yesterday the CDC updated their guidelines for people who are fully vaccinated. They now say that fully vaccinated people can:

  • Visit with other fully vaccinated people indoors without wearing masks or physically distancing.
  • Visit with unvaccinated people from a single household who are at low risk for severe COVID-19 disease indoors without wearing masks or physically distancing.
  • Refrain from quarantining and testing following a known exposure to someone with COVID-19 unless you develop symptoms.

The other CDC guidelines remain in place for now but are likely to change once a larger percentage of the population has been vaccinated.

#4: Why Not Rely On Diet And Supplementation? I have friends who tell me they are not going to get Vaccination Perspectivevaccinated. They will rely on diet and supplementation to keep their immune systems strong and protect them from COVID. I respect their choice.

In fact, I have a great deal of sympathy for that choice. When I think of protecting myself from colds and flu, my preference has always been to keep my immune system strong with diet, supplementation, and exercise rather than relying on vaccinations.

However, COVID is different story. It is a far deadlier disease. And even if it doesn’t kill you, it may impact your life for years to come. The long-term health consequences of COVID are perhaps even scarier than the 1% death rate.

Let’s take a realistic look at each of our options to defeat COVID:

  • In a previous issue of “Health Tips From the Professor” I shared some preliminary clinical studies showing that people with adequate vitamin D status were 60-70% less likely to be infected with COVID, hospitalized with COVID, in the ICU from COVID, and dying from COVID. That is impressive, but it is not 100% protection. And if your vitamin D levels are already adequate, you get no additional benefit from adding extra vitamin D to your diet.
  • In another issue of “Health Tips From the Professor” I shared a review written by a group of experts on respiratory diseases. They concluded that, in addition to a good diet, supplementation with a multivitamin and extra vitamin C, vitamin D, and omega-3s reduced the risk of dying from respiratory diseases. But they didn’t say it eliminated the risk. It did not guarantee 100% protection.
  • As for CDC guidelines, wearing a mask gives you somewhere between 30 and 70% protection. Social distancing and handwashing also help, but they don’t offer 100% protection.
  • Vaccination with the Pfizer and Moderna vaccines gives you at least 60% protection against upper respiratory infections from COVID-19 and 95% protection against severe disease, hospitalization, long term health consequences, and death. It is the single most effective tool we have at our disposal, but it does not give 100% protection. As one of my pessimist friends put it, “95% protection means I have a 1 in 20 chance of getting it.”

COVID-19 is throwing everything it has at us. When faced with a deadly disease and several things I can do that offer partial protection, I choose a holistic approach. I choose to use every tool at my disposal. I choose diet, supplementation, CDC guidelines, and vaccination. Everyone should make their own decision about how best to protect themselves from COVID-19, but my choice is clear. I want to do everything in my power to avoid this disease.

The Bottom Line 

In the article above, I have updated my information on vaccines with data from the latest studies, provided you with resources about the vaccines you can share, and have given you updates and perspective on the four biggest unanswered questions about COVID-19 and the vaccines, namely:

  • How long does immunity last?
  • Do we need to fear the new variants?
  • Can I get my life back after vaccination?
  • Why not rely on diet and supplementation?

For more details, read the article above.

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.

Does Vitamin D Affect IQ?

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The Importance Of Vitamin D During Pregnancy

Author: Dr. Stephen Chaney

pregnant women taking vitaminAs an expectant mother, you want the best for your child. You want them to be healthy and happy. You probably also want them to be smart.

Your doctor has recommended you take a prenatal supplement. You have probably heard about the importance of folic acid for a successful pregnancy. I have also written about the importance of adequate omega-3s and iodine during pregnancy for the cognitive development of your child.

But what about vitamin D? Vitamin D receptors are expressed in the mammalian brain as early as 12 days into gestation, and vitamin D is thought to be important in neurocognitive development.

Previous studies have shown that vitamin D deficiency during pregnancy is associated with delayed motor-skill and social development during the first few years of childhood. But it is uncertain whether these early deficits translate into long-term deficits in IQ and emotional stability.

This study was designed to answer that question by comparing blood 25-hydroxyvitamin D levels in the mother’s blood during the second trimester and IQ measurements of their children between the ages of 4 and 6.

How Was This Study Done?

Clinical StudyThis study used data from the CANDLE (Conditions Affecting Neurocognitive Development and Learning in Early Childhood) database. This portion of the study measured blood levels of 25-hydroxyvitamin D during the second trimester of pregnancy of 1503 women from the Memphis area of Tennessee. The 25-hydroxyvitamin D levels were compared with the IQ of their children measured between the ages of 4 and 6.

The average age of the mothers was 26 and 63% of them were black.

Of course, there are many other factors that influence mental development during childhood. Accordingly, the data were corrected for the overall quality of the maternal diet, maternal IQ, maternal education, maternal age, marital status, BMI (a measure of obesity), tobacco use during pregnancy, alcohol use during pregnancy, and household income.

Does Vitamin D Affect IQ?

child geniusHere are the results from the study:

  • The average blood level of 25-hydroxyvitamin D at week 23 of pregnancy was 21.6 ng/mL.
    • 45.6% of the women were vitamin D deficient (<20 ng/mL 25-hydroxyvitamin D).
  • The average blood level of 25-hydroxyvitamin D in this study was 19.8 ng/mL for Black women and 25.9 ng/mL for White women.
    • This is consistent with a previous report that 80% of Black pregnant women in this country are vitamin D deficient compared to only 13% of White pregnant women.
  • After adjusting for other variables known to affect IQ, every 10ng/mL increase in 25-hydroxyvitamin D status during pregnancy resulted in an increase of:
    • 1.17 points in overall IQ.
    • 1.17 points in verbal IQ.
    • 1.03 points in nonverbal IQ.
  • The effect of vitamin D status during pregnancy on IQ of the offspring at ages 4-6 was the same for both races.
  • The effect of maternal vitamin D status on childhood IQ plateaued at around 40ng/mL, which is near the top of what is considered an adequate level of 25-hydroxyvitamin D.

The authors of the study concluded: “Gestational vitamin D concentrations were positively associated with IQ at age 4-6, suggesting that vitamin D plays an important role in programming neurocognitive development. Vitamin D status may be an important modifiable factor that can be optimized through appropriate nutritional recommendations and guidance. Vitamin D deficiency was especially prevalent among Black women in this cohort, suggesting a higher need for screening and nutritional intervention in this vulnerable population.”

The authors went on to say: “Vitamin D supplementation may be indicated for women who have poor dietary intake of vitamin D and/or reduced cutaneous synthesis related to skin pigmentation [Simply put, sunlight can catalyze the synthesis of vitamin D in our skin, but skin pigmentation filters out the sunlight and decreases vitamin D synthesis.]…”

The Importance Of Vitamin D During Pregnancy

vitamin dLet me put this study in perspective by first discussing the pros and cons of the study. Then I will close with what I think is the most important takeaway from the study.

The Cons Of The Study:

The cons are obvious:

  1. This study shows that a 10 ng/mL increase in 25-hydroxyvitamin D during pregnancy is associated with about a 1-point increase in IQ on a 100-point scale? Is that significant? Probably not, especially when you consider all the other dietary and environmental factors that influence intelligence and educational attainment.

2) We don’t know whether this effect of vitamin D status during pregnancy on IQ will persist as the children grow up. It is more likely that socioeconomic and family factors during childhood will play a much larger role in educational attainment.

The Pros Of The Study:

  1. This study is superior to most previous studies on this topic because of its size and duration. It is also a well-designed study.

2) The authors pointed out a previous study has reported that for each decrease of one IQ point:

    • Lifetime income for men decreases by 1.93%.
    • Lifetime income for women decreases by 3.23%.

3) The effect of vitamin D status during pregnancy on IQ at age 4-6 plateaued at 40 ng/mL. That means the women in this study would obtain optimal benefit by increasing their 25-hydroxyvitamin D levels by 20 ng/mL. Since each 10 ng/mL increase in 25-hydroxyvitamin D during pregnancy increased IQ by 1.17, this would translate into:

  • A 4.5% increase in lifetime earnings for men.
  • A 7.6% increase in lifetime earnings for women.
  • When you look at it this way, the effect of vitamin D during pregnancy on IQ seems a bit more significant.

The Most Important Takeaway From This Study:

  • Of all the things you can do during pregnancy to give your kids an advantage in today’s competitive world, supplementation with vitamin D before and during pregnancy is probably the simplest, cheapest, and safest option available to you.
  • Even if optimizing 25-hydroxyvitamin D levels during pregnancy has no long-term effect on your child’s IQ, we know it has many other benefits for your health and your child’s health.
  • And, as long as you don’t exceed 50 ng/mL of 25-hydroxyvitamin D, it is perfectly safe.

The authors had this to say about supplementation with vitamin D before and during pregnancy: “Popular prenatal supplements, which typically contain 400-600 IU vitamin D, are likely insufficient to correct 25-hydroxyvitamin D deficiencies. Randomized controlled trials have suggested that daily supplementation of 800 to 1,000 may be needed during pregnancy, and that doses of 4,000 IU may be ideal in cases of severe deficiency.”

The Bottom Line

A recent study looked at 25-hydroxyvitamin D status during the second trimester of pregnancy and the IQ of the offspring at ages 4-6. The study found:

  • The average blood level of 25-hydroxyvitamin D at week 23 of pregnancy was 21.6 ng/mL.
    • 6% of the women were vitamin D deficient (<20 ng/mL 25-hydroxyvitamin D).
    • After adjusting for other variables known to affect IQ, every 10ng/mL increase in 25-hydroxyvitamin D status during pregnancy resulted in an increase of 1.17 points in overall IQ.
  • The effect of maternal vitamin D status on childhood IQ plateaued at around 40ng/mL, which is near the top of what is considered an adequate level of 25-hydroxyvitamin D.

The authors of the study concluded: “Gestational vitamin D concentrations were positively associated with IQ at age 4-6, suggesting that vitamin D plays an important role in programming neurocognitive development. Vitamin D status may be an important modifiable factor that can be optimized through appropriate nutritional recommendations and guidance…”

The authors went on to say: “Vitamin D supplementation may be indicated for women who have poor dietary intake of vitamin D and/or reduced cutaneous synthesis related to skin pigmentation…”

In terms of supplementation, the authors said: “Popular prenatal supplements, which typically contain 400-600 IU vitamin D, are likely insufficient to correct 25-hydroxyvitamin D deficiencies. Randomized controlled trials have suggested that daily supplementation of 800 to 1,000 may be needed during pregnancy, and that doses of 4,000 IU may be ideal in cases of severe deficiency.”

For more details and my perspective of the study, read the article above.

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.

Does Vitamin D Prevent Depression?

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Why You Can’t Believe Everything You Read

depressionThe days are getting shorter and Seasonal Depression, often called the “winter blues”, will soon be upon us. Most of the research on Seasonal Depression has centered on the effect of sunlight on our hormones.

However, sunlight is also responsible for the synthesis of vitamin D in our skin cells. So, some experts have hypothesized that low levels of 25-hydroxyvitamin D, the active form of vitamin D, in our blood also play a role in the winter blues.

If so, that could have important implications for managing depression, especially in older adults. Depression is estimated to affect around 6.5 million of the 49 million adults over the age of 65 in our country. Treatment costs for older adults in this country are estimated at $9 billion/year.

If something as simple and inexpensive as a vitamin D supplement could reduce the risk of depression, it would be a huge boon to our health care system.

Association studies suggest that may be a possibility. For example, one recent meta-analysis of 6 clinical studies (H Li et al, The American Journal of Geriatric Psychiatry, 27: P1192-1202, 2019) reported that every 10 ng/mL increase in 25-hydroxyvitamin D was associated with a 12% decrease in the risk of depression in older adults.

However, association studies do not prove cause and effect.

Unfortunately, randomized, placebo controlled clinical trials have given mixed results. A few studies suggested that vitamin D might reduce depression risk, but most of the studies found no effect of vitamin D on depression risk. However, most of the published studies have been poorly designed They were too small, too short, or did not use validated methods for measuring depression.

This was the genesis of the current study (OI Okerke et al., JAMA, 324: 471-480, 2020). It was designed to be a definitive study that would avoid the defects of previous studies.

The study concluded that vitamin D supplementation does not decrease the risk of depression in older adults, and those were the headlines you have probably seen. But is that conclusion true? Let’s take a peek behind the curtain and analyze the study.

How Was The Study Done?

Clinical StudyThis study was an offshoot of the VITAL (VITamin D and OmegaA-3 TriaL) clinical study, so let me start by describing the characteristics of that study.

The VITAL study (JE Manson et al, New England Journal of Medicine, DOI: 10.1056/NEJMoa1811403) enrolled 25,871 healthy adults (average age = 67) in the United States. The study participants were 50% female, 50% male, and 20% African American. None of the participants had preexisting cancer or heart disease.

Study participants were given questionnaires on enrollment to assess clinical and lifestyle factors including dietary intake. Blood samples were taken from about 65% of the participants to determine 25-hydroxyvitamin D levels (a measure of vitamin D status) at baseline and at the end of the first year to assess the effectiveness of vitamin D supplementation. The participants were given either 2,000 IU of vitamin D/day or a placebo and followed for an average of 5.3 years.

This study consisted of 18,353 participants from the VITAL study. Ninety percent of the participants had no previous history of depression. Ten percent had previously been diagnosed or treated for depression but had been depression-free for over 2 years.

The participants filled out annual questionnaires to quantify the onset of depression by three criteria:

  • A diagnosis of depression by a physician.
  • Treatment for depression (medications, counseling, or both).
  • A questionnaire designed to evaluate symptoms of depression. The authors of the study referred to this as an assessment of their mood.

During the 5.3 year follow up period 3.6% of the participants reported the onset of diagnosed depression or a mood consistent with depression. This is consistent with previous studies showing that 1-5% of healthy, non-institutionalized older adults suffer from depression.

Does Vitamin D Prevent Depression?

thumbs down symbolThe results of the study were clear.

Treatment with 2,000 IU of vitamin D3 compared to placebo for 5.3 years did not have a statistically significant effect on:

  • The incidence or recurrence of depression diagnosis, or…
  • Treatment for depression, or…
  • Clinically relevant depressive symptoms.

The authors concluded, “These findings do not support the use of vitamin D3 in adults to prevent depression.”

Why You Can’t Believe Everything You Read

It would be tempting to say, “Case closed. We now know for certain that vitamin D has no effect on depression.”

After all, this was an excellent study. It was large (18,353 participants), lasted a long time (5.3 years), and used well established measures of depression. What’s not to like?

Peek Behind The CurtainUnfortunately, even well-designed studies can give misleading results. Let’s take a peek behind the curtain and see where this study went astray.

There were two glaring deficiencies in this study.

#1: Most of the participants had adequate vitamin D status at the beginning of the study. The average 25-hydroxyvitamin D level of participants at the beginning of the study was 31 ng/mL (78 nmol/L). The NIH considers 20-50 ng/mL (50-125 nmol/L) to be an adequate level of 25-hydroxyvitamin D for most physiological functions. This means that study participants started in the middle of the adequate range with respect to vitamin D status.

This was not a failure of study design. In fact, the authors of the study are to be commended for measuring the vitamin D status of participants at the beginning of the study. Many previous studies have neglected to do that.

The problem is that vitamin D has become extremely popular. Many Americans are already taking multivitamins or vitamin D supplements. To recruit enough people for the study the authors were forced to allow participants to enter the study even if they were taking vitamin D supplements, as long as the amount did not exceed 800 IU/day.

In short, most of the participants in this study were already supplementing with up to 800 IU/day of vitamin D. If so, they were allowed to continue taking their vitamin D supplements. The 2,000 IU of vitamin D was added to what they were already taking.

The question then becomes, if people are already taking RDA levels of supplemental vitamin D and their blood levels of 25-hydroxyvitamin D are already in the adequate range, do we really expect additional supplemental vitamin D to have a beneficial effect?

The author’s answer to that question was, “The mean baseline 25-hydroxyvitamin D level was 30.8 ng/mL; this value is already at a threshold for extraskeletal health benefits [health benefits other than bone health], and so the ability to observe effects of vitamin D3 supplementation may have been attenuated. [To determine whether vitamin D supplementation reduces the risk of depression] large-scale studies would be required to address the effects of high-dose, long-term vitamin D3 supplementation among those with nutrient deficiency.”

My more direct answer would be, “This study provides no useful information on whether vitamin D3 supplementation reduces the risk of depression. What is needed are studies that start with a population that is deficient in vitamin D.”

An accurate conclusion from this study would have been, “If you are already taking vitamin D supplements and/or have an adequate vitamin D status, supplementation with an extra 2,000 IU of vitamin D3 provides no additional benefit with respect to the risk of developing depression.” But that is not what the headlines said.

#2: The study did not record the reason for the onset of depression. That is important because the top 3 causes of depression in adults 65 and older are:

  • Loss of a spouse or partner.
  • Chronic health issues.
  • Restricted blood flow to the brain.

It is unlikely that vitamin D supplementation would have much of an effect on these issues.

In contrast, seasonal depression, which is more likely to be affected by vitamin D supplementation, was not measured in this study.

The Bottom Line

You may have seen recent headlines saying that vitamin D supplementation has no effect on the risk of developing depression.

The study behind these headlines was a very well-designed study. It was large (18,353 participants), lasted a long time (5.3 years), and used well established measures of depression.

It would be tempting to say, “Case closed. We now know for certain that vitamin D supplementation has no effect on depression.”

Unfortunately, even well-designed studies can give misleading results. This one had a major flaw that made the data almost useless.

The problem is that most Americans are already taking multivitamins or vitamin D supplements. To recruit enough people for the study the authors were forced to allow participants to enter the study even if they were taking vitamin D supplements, as long as the amount did not exceed 800 IU/day.

That meant that most participants already had adequate blood levels of 25-hydroxyvitamin D at the beginning of the study.

The question then becomes, if people are already taking RDA levels of supplemental vitamin D and their blood levels of 25-hydroxyvitamin D are already in the adequate range, do we really expect additional supplemental vitamin D to have a beneficial effect? The answer is, “Probably not”.

Rather than saying that this study definitively shows that vitamin D supplementation has no effect on the risk of developing depression, I feel it would be more accurate to say, “This study provides no useful information on whether vitamin D3 supplementation reduces the risk of depression. What is needed are studies that start with a population that is deficient in vitamin D.”

An accurate conclusion from this study would have been, “If you are already taking vitamin D supplements and/or have an adequate vitamin D status, supplementation with an extra 2,000 IU of vitamin D3 provides no additional benefit with respect to the risk of developing depression.” But that is not what the headlines said.

For more details, read the article above.

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.

The Truth About Vitamin D And Respiratory Diseases

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How Should You Prepare For This Winter?

deadSome health experts are making dire predictions for this fall when COVID-19 overlaps with our annual flu season. People are worried.

When people are worried, hucksters smell a quick buck and start coming out of the woodworks. They are touting all sorts of miracle pills and potions that will keep us safe this winter. The FDA is doing its best to shut them down, but it’s like the “Whack A Mole” game you may remember from the county fair. As soon as the FDA shuts one down, another pops up.

In the meantime, you are left trying to sort through the claims. I could write a whole book on the truth (and lies) about the claims you are seeing on the internet. But this week I will focus on vitamin D. I will give you unbiased answers to three questions.

1) What is the truth about vitamin D and respiratory disease?

2) Will vitamin D help protect you against COVID-19?

3) How should you prepare for this winter?

I am basing today’s “Health Tip” on a recently published study (H Brenner et al, Nutrients 2020, 12, 2488) looking at the effect of vitamin D status on deaths from respiratory disease in older German adults.

How Was The Study Done?

Clinical StudyThe data from this study were taken from an ongoing study in Germany looking at the effect of diet and lifestyle on health outcomes in older adults. In this case, 9548 adults, ages 50-75, from the region of Saarland in Germany were enrolled in the study between 2000 and 2002 and followed for an average of 15 years.

Blood samples were drawn at the time of enrollment and 25-hydroxyvitamin D levels were determined as a measure of vitamin D status. Deaths and cause of deaths over the 15 year period were obtain from German health records.

The basic characteristics of the study population were:

  • The gender breakdown was 43.8% men, 52.6% female.
  • The average age was 62.1 years.
  • Almost all participants were Caucasians of German or French descent.
  • 8% were vitamin D insufficient (25-hydroxyvitamin D of 30-<50 nmol/L)
  • 1% were vitamin D deficient (25-hydroxyvitamin D of <30 nmol/L)

Note: Almost 60% of this study group had an inadequate vitamin D status. The comparable figures for the US population are 42% with inadequate vitamin D status (34% vitamin D insufficient and 8% vitamin D deficient).

The reasons for this are likely two-fold:

  • Saarland is at the latitude of Newfoundland, Canada, so sun exposure is less than for most Americans.
  • Germans are less likely to consume supplements than Americans.

However, the fact that 60% of this study group has inadequate vitamin D status makes it a particularly good group to look at the effect of vitamin D status on health outcomes.

The Truth About Vitamin D And Respiratory Diseases

the truth signThis study found:

  • Vitamin D insufficiency (25-hydroxyvitamin D of 30-<50 nmol/L) increased the risk of dying from respiratory disease by 1.9-fold for men and 2.1-fold for women.
  • Vitamin D deficiency (25-hydroxyvitamin D of <30 nmol/L) increased the risk of dying from respiratory disease by 2.3-fold for men and 3.0-fold for women.

The authors pointed out that this was consistent with a recent meta-analysis of randomized clinical trials showing that supplementation with RDA levels of vitamin D reduced the risk of acute respiratory tract infections by 70% in people who were vitamin D deficient.

The authors concluded:

“Vitamin D insufficiency and deficiency are common and account for a large proportion of respiratory disease mortality in older adults…Our results, along with evidence from meta-analyses from RCTs [Randomized Placebo-Controlled Clinical Trials] regarding results of vitamin D3 supplementation on various outcomes, suggest that vitamin D3 supplementation could contribute to lowering mortality from respiratory and other diseases during and beyond the COVID-19 pandemic, particularly among women.”

How Should You Prepare For This Winter?

Winter WindNow it is time to answer the three questions I posed at the beginning of this article:

1) What is the truth about vitamin D and respiratory disease?

There have been many studies suggesting that inadequate vitamin D status increases the risk of “catching” respiratory diseases such as the seasonal flu. Some of those studies showed that supplementation with vitamin D3 reduced the risk of catching respiratory diseases. However, most of those were small studies.

This study and the meta-analysis the authors referred to were much larger, better designed studies. Other large, well designed studies are needed. But, taken together, these two studies strongly support the hypothesis that inadequate vitamin D status significantly increases the risk of developing and dying from respiratory diseases.

However, we do need to put this into perspective.

  • Supplementation with vitamin D primarily protects individuals with inadequate vitamin D status. It doesn’t appear to offer significant benefit for individuals with adequate vitamin D status (>50 nmol/L 25-hydroxyvitamin D).
  • Supplementation with vitamin D at doses of 2,000 IU or less appears to be sufficient for most people. There is little evidence that megadoses are beneficial unless you are severely vitamin D deficient (more about that below).

2) Will vitamin D help protect you against COVID-19?

vitamin dThe answer to this question is less clear. As we learn more about COVID-19 we have learned that it is much more than just a respiratory disease. On the other hand, cellular studies suggest that vitamin D may interfere with the mechanism by which COVID-19 attacks cells.

What do clinical studies say? We are just learning. Four small clinical trials and one large study have recently been published or posted online as preprints prior to being accepted for publication.

  • The second study (HW Kaufman et al, PLOS One, September 17, 2020) used data from a major national testing center (Quest Diagnostics) and linked COVID-19 test results with 25-hydroxyvitamin D test results for 191,779 patients. This study reported that vitamin D deficiency was associated with a 30% increased risk of testing positive for COVID-19.
  • The third study found that vitamin D deficiency was associated with hospital admissions for COVID-19.
  • The fourth study found that vitamin D deficiency was associated ICU admissions for COVID-19.

Taken together these 5 studies suggest that vitamin D deficiency may increase the risk of being infected by COVID-19 and on the severity of the disease if you are infected.

I should point out that these studies are preliminary. Normally we would say that they need to be confirmed by larger studies before becoming incorporated into the standard of care for COVID-19.

You might be saying to yourself, , “Why is the medical community paying so much attention to preliminary studies?” The answer is simple:

  • The need is urgent. We need all the tools at our disposal to fight this deadly disease, and we need them now.
  • Vitamin D3 supplementation at 2,000 IU or less is inexpensive and safe. Plus, even if further studies find that our vitamin D status has no effect on COVID-19 risk, we know that adequate vitamin D has many other potential health benefits.

To summarize:

  • Preliminary studies suggest that adequate vitamin D status may offer some protection for COVID-19. These studies are not definitive. No reputable scientist is ready to tell you that vitamin D will ward off COVID-19. However, supplementation with 2000 IU/day or less of vitamin D3 is safe and may have multiple health benefits.
  • Vitamin D should not be considered a “magic bullet”. It is just one aspect of a holistic approach to creating a healthy body that is less susceptible to respiratory diseases like COVID-19.

3) How Should You Prepare For This Winter?

Winter WindAs we approach the winter months, the days are getting shorter and sun exposure is decreasing. This is the time of year when your 25-hydroxyvitamin D levels will be at their lowest.

At the same time, we are likely to see a convergence of the seasonal flu, flu-like illnesses, and COVID-19 this winter. You will need a healthy body, a healthy immune system, and adequate vitamin D status more than ever.

When asked about vitamin D and COVID-19 in a recent interview, Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases, said, “If you’re deficient in vitamin D, that does have an impact on your susceptibility to infection. I would not mind recommending, and I do it myself, taking vitamin D supplements.”

I recommend supplementation with vitamin D3 to make sure your vitamin D status is adequate. The RDA for vitamin D is 600 IU for adults and 800 IU for seniors over the age of 70. However, because the efficiency with which we convert vitamin D3 to 25-hydroxyvitamin D varies from person to person, many experts recommend supplementing with 1,500-2,000 IU of vitamin D3.

I also recommend that you ask your health provider for a 25-hydroxyvitamin D test. If you are in the vitamin D deficient range, your health provider may recommend more than 2,000 IU/day of vitamin D3.

Finally, we should not rely on vitamin D alone. As I discussed in a previous issue of “Health Tips From The Professor”, I recommend a holistic approach for strengthening our immune systems, and I recommend the CDC guidelines for reducing the risk of catching both the flu and COVID-19.

I would note that social distancing, hand washing, and mask wearing are just as effective at reducing the risk of getting the flu as they are for getting COVID-19. In fact, some Asian countries practice mask wearing in public every flu season.

The Bottom Line

  • A recent study found that inadequate vitamin D status caused a 2-3-fold increased risk of dying from respiratory illnesses for seniors (ages 50-74).
  • A previous meta-analysis reported that supplementation with RDA levels of vitamin D reduced the risk of acute respiratory tract infections by 70% in people who were vitamin D deficient.
  • Taken together, these two studies strongly support the hypothesis that inadequate vitamin D status significantly increases the risk of developing and dying from respiratory diseases.
  • Preliminary studies suggest that adequate vitamin D status may offer some protection for COVID-19. These studies are not definitive. No reputable scientist is ready to tell you that vitamin D will ward off COVID-19. However, supplementation with 2000 IU/day or less of vitamin D3 is safe and may have multiple health benefits.
  • Vitamin D should not be considered a “magic bullet”. It just one aspect of a holistic approach to creating a healthy body that is less susceptible to respiratory diseases like COVID-19.

So, how should we prepare for this winter?

  • As we approach the winter months, the days are getting shorter and sun exposure is decreasing. This is the time of year when your 25-hydroxyvitamin D levels will be at their lowest.
  • At the same time, we are likely to see a convergence of the seasonal flu, flu-like illnesses, and COVID-19 this winter. You will need a healthy body, a healthy immune system, and adequate vitamin D status more than ever.
  • I recommend supplementation with vitamin D3 to make sure your vitamin D status is adequate. The RDA for vitamin D is 600 IU for adults and 800 IU for seniors over the age of 70. However, because the efficiency with which we convert vitamin D3 to 25-hydroxyvitamin D varies from person to person, many experts recommend supplementing with 1,500-2,000 IU of vitamin D3.
  • Finally, we should not rely on vitamin D alone. As I discussed in a previous issue of “Health Tips From The Professor”, I recommend a holistic approach for strengthening our immune systems, and I recommend the CDC guidelines for reducing the risk of catching both the flu and COVID-19.

I would note that social distancing, hand washing, and mask wearing are just as effective at reducing the risk of getting the flu as they are for getting COVID-19. In fact, some Asian countries practice mask wearing in public every flu season.

For more details, read the article above.

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.

Does Poverty Affect Nutritional Status?

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How Can We Improve Nutrition In Disadvantaged Communities?

Calcium FoodsRecently there has been increased focus on health disparities in disadvantaged communities. In our discussions of the cause of these health disparities, two questions seem to be ignored.

1. Does poverty play a role in poor nutrition?

2. Does poor nutrition play a role in the health disparities we see in disadvantaged communities?

The study (K Marshall et al, PLoS One 15(7):e0235042) I discuss in this week’s “Health Tips From The Professor” attempts to address both of these questions.

Before, I start, let me put this study into context.

  • Osteoporosis is a major health problem in this country. Over 2 million osteoporosis-related fractures occur each year, and they cost our health care system over 19 billion dollars a year. Even worse, for many Americans these osteoporosis-related fractures often cause:
    • A permanent reduction in quality of life.
    • Immobility, which can lead to premature death.
  • Inadequate calcium and vitamin D intakes increase the risk of osteoporosis.

While most studies simply report calcium and vitamin D intakes for the general population, this study breaks them down according to ethnicity and income levels. The results were revealing.

How Was The Study Done?

Clinical StudyThis study drew on data from the 2007-2010 and 2013-2014 National Health and Nutrition Examination Surveys (NHANES). These surveys are conducted by the National Center for Health Statistics, which is part of the CDC. They are designed to assess the health and nutritional status of adults and children in the United States and are used to produce health statistics for the nation.

The NHANES interview includes demographic, socioeconomic, dietary, and health-related questions. The examination component consists of medical, dental, and physiological measurements, as well as laboratory tests administered by highly trained medical personnel. All participants visit a physician. Dietary interviews and body measurements are included for everyone.

This study measured calcium intake, vitamin D intake, and osteoporosis for adults 50 and older. The data were separated by gender, ethnic group and income level. Four different measures of poverty were used. For purposes of simplicity, I will only use one of them, income beneath $20,000, for this article.

Does Poverty Affect Nutritional Status?

The Effect of Ethnicity And Gender On Calcium And Vitamin D Intake: 

FriendsWhen the authors looked at the effect of ethnicity and gender on calcium and vitamin D intake, in people aged 50 and older the results were (Note: I am using the same ethnic nomenclature used in the article):

Hispanics:

    • 66% (75% for women and 56% for men) were getting inadequate calcium intake.
    • 47% (47% for women and 47% for men) were getting inadequate vitamin D intake.

Non-Hispanic Blacks:

    • 75% (83% for women and 64% for men) were getting inadequate calcium intake.
    • 53% (51% for women and 54% for men) were getting inadequate vitamin D intake.

Non-Hispanic Whites:

    • 60% (64% for women and 49% for men) were getting inadequate calcium intake.
    • 33% (30% for women and 37% for men) were getting inadequate vitamin D intake.

For simplicity, we can generalize these data by saying:

Gender:

    • Women are more likely to be calcium-deficient than men.
    • Men are more likely to be vitamin D-deficient than women.

Ethnicity: For both genders and for both calcium and vitamin D:

    • The rank order for deficiency is Non-Hispanic Blacks > Hispanics > Non-Hispanic Whites.

The Effect Of Poverty On Calcium Intake, Vitamin D Intake, And Osteoporosis:

PovertyWhen looking at the effect of poverty, the authors asked to what extent poverty (defined as income below $20,000/year) increased the risk of calcium and vitamin D deficiency in adults over 50. Here is a summary of the data

Hispanics:

    • For both Hispanic women and Hispanic men, poverty had little effect on the risk of calcium and vitamin D deficiency.

Non-Hispanic Blacks:

    • For Non-Hispanic Black women, poverty had little effect on the risk of calcium deficiency, and vitamin D deficiency.
    • For Non-Hispanic Black men, poverty increased the risk of both calcium and vitamin D deficiency by 32%.

Non-Hispanic Whites:

    • For Non-Hispanic White women, poverty had little effect on the risk of calcium deficiency but increased the risk of vitamin D deficiency by 30%.
    • For Non-Hispanic White men, poverty increased the risk of both calcium deficiency and vitamin D deficiency by 18%.

For simplicity, we can generalize these data by saying:

    • Poverty increased the risk of both calcium and vitamin D deficiency for Non-Hispanic Black men, Non-Hispanic White women, and Non-Hispanic White men.

Other statistics of interest:

  • The SNAP program (formerly known as Food Stamps) had little effect on calcium and vitamin D intake. There are probably two reasons for this:
    • In the words of the authors, “While the SNAP program has been shown to decrease levels of food insecurity, the quality of the food consumed by SNAP participants does not meet the standards for a healthy diet.” In other words, the SNAP program ensures that participants have enough to eat, but SNAP participants are just as likely to prefer junk and convenience foods as the rest of the American population. The SNAP program provides no incentive to eat healthy foods.
    • We also need to remember that dairy foods are a major source of calcium and vitamin D in the American diet and that Hispanics and Non-Hispanic Blacks are more likely to be lactose-intolerant than the rest of the American population. There are other sources of calcium and vitamin D in the American diet. But without some nutrition education, most Americans are unaware of what they are.
  • An increased risk of osteoporosis was found in Non-Hispanic Black men, and Non-Hispanic Whites with incomes below $20,000/year.
    • This increased risk of osteoporosis was seen primarily for the individuals in each group who were deficient in calcium and vitamin D. There were other factors involved, but I will focus primarily on the effect of poverty on calcium and vitamin D intake in the discussion below.

How Can We Improve Nutrition In Disadvantaged Communities?

Questioning WomanLet’s start with the two questions I posed at the beginning of this article:

1. Does poverty play a role in poor nutrition?

2. Does poor nutrition play a role in the health disparities we see in disadvantaged communities?

In terms of calcium intake, vitamin D intake, and the risk of osteoporosis, the answer to both questions appears to be, “Yes”. So, the question becomes, “What can we do?”

It is when we start to ask what we can do to increase calcium and vitamin D intake and decreased the risk of osteoporosis in disadvantaged communities that we realize the complexity of the problem. There are no easy answers. Let’s look at some of the possibilities.

[Note: I am focusing on what we can do to prevent osteoporosis, not to detect or treat osteoporosis. The solutions for those issues would be slightly different.]

1. We could increase funding for SNAP. That would increase the quantity of food available for low income families, but, as noted above, would do little to improve the quality of the food eaten.

2. We could improve access to health care in disadvantaged communities. But unless physicians started asking their patients what they eat and start recommending a calcium and vitamin D supplement when appropriate, this would also have little impact on diet quality.

3. We could improve nutrition education. A colleague of mine in the UNC School of Public Health ran a successful program of nutrition education through churches and community centers in disadvantaged communities for many years. The program taught people how to eat healthy on a limited budget. Her program improved the health of many people in disadvantaged communities.

However, the program was funded through grants. When she retired, federal and state money to support the program eventually dried up. The program she started is a model for what we should be doing.

4. The authors suggested food fortification as a solution. In essence, they were suggesting that junk and convenience foods be fortified with calcium and vitamin D. That might help, but I don’t think it is a good idea.

If we want to improve the overall health of disadvantaged communities, we need to find ways to replace junk and convenience foods with healthier foods. Adding a few extra nutrients to unhealthy foods does not make them healthy.

5. The authors also said that a calcium and vitamin D supplement would be a cheap and convenient way to eliminate calcium and vitamin D deficiencies. Unfortunately, supplements are currently not included in the SNAP program. Unless that is changed, even inexpensive supplements are a difficult choice for families below the poverty line.

As I said at the beginning of this section, there are no easy answers. It is easy to identify the problem. It would be easy to throw money at the problem. But finding workable solutions that could make a real difference are hard to identify.

Yes, we should make sure every American has enough to eat. Yes, we should make sure every American has access to health care. But, if we really want to improve the health of our disadvantaged communities, we also need to:

  • Change the focus of our health care system from treatment of disease to prevention of disease.
  • Train doctors to ask their patients what they eat and to instruct their patients how simple changes in diet could dramatically improve their health.
  • Provide basic nutrition education to disadvantaged communities at places where they gather, like churches and community centers. This would cover topics like eating healthy, shopping healthy on a limited budget, and cooking healthy.

We don’t necessarily need another massive federal program. But those of us with the knowledge could each volunteer to share that knowledge in disadvantaged communities.

  • Cover basic supplements, like multivitamins, calcium and vitamin D supplements, and omega-3 supplements in food assistance programs like SNAP.

The Bottom Line

Osteoporosis is a major health problem in this country. Over 2 million osteoporosis-related fractures occur each year, and they cost our health care system over 19 billion dollars a year. Even worse, for many Americans these osteoporosis-related fractures often cause:

  • A permanent reduction in quality of life.
  • Immobility, which can lead to premature death.

We know that inadequate calcium and vitamin D intakes increase the risk of osteoporosis. But most studies simply report calcium and vitamin D intakes for the general population. At the beginning of this article, I posed two questions.

  1.  Does poverty play a role in poor nutrition?

2. Does poor nutrition play a role in the health disparities we see in disadvantaged communities?

A recent study looked at the effect of gender, ethnicity and income levels on calcium intake, vitamin D intake, and the risk of developing osteoporosis. The results of this study shed some light on those two questions.

When looking at the effect of gender and ethnicity on the risk of inadequate calcium and vitamin D intake, the study found:

  • Women are more likely to be calcium-deficient than men.
  • Men are more likely to be vitamin D-deficient than women.
  • For both genders and for both calcium and vitamin D, the rank order for deficiency is Non-Hispanic Blacks > Hispanics > Non-Hispanic Whites. [Note: Note: I am using the same ethnic nomenclature used in the study.]
  • Poverty (defined as incomes below $25,000/year) significantly increased the risk of both calcium and vitamin D deficiency for Non-Hispanic Black men, Non-Hispanic White women, and Non-Hispanic White men.
  • An increased risk of osteoporosis was also found in Non-Hispanic Black men, and Non-Hispanic White men and women with incomes below $20,000/year.
  • This increased risk of osteoporosis was seen primarily for the individuals in each group who were deficient in calcium and vitamin D.

In short, this study suggests that the answer to both questions I posed at the beginning of the article is, “Yes”.

For more information and a discussion of what we could do to correct this health disparity in disadvantaged communities, read the article above.

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