Tag Archive for: calcium

Reality Check: Vitamin D

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Let me be clear. You should know how much of every dietary supplement you take and why you take it. If you exceed the amounts recommended on the label, you should also know why. But the case of the 89-year-old man who died because of an assumed excess vitamin D intake shouldn’t change a reasonable intake of vitamin D for anybody. Let’s take a look at what we don’t know.

Unanswered Questions

How much vitamin D was he taking? There is no indication that he took more than the upper limit. The assumption was that he was taking a very high amount, but wouldn’t there be receipts from pharmacies or groceries where he bought the supplements to deduce an estimate of how much he took?

Why did he decide to take more? Was he not feeling well? Someone with chronic heart disease and kidney disease might not feel all that great.

What medications was he taking? Was he taking those at the right time in the proper quantities?

One more: How do we know how he processed vitamin D? The assumption was that he mega-dosed on vitamin D, but what if he simply couldn’t process it well at 89?

About Exceeding That Upper Limit

For adults, the Tolerable Upper Limit (TUL) is listed at 4,000 IU (100 mcg), but that includes a safety factor of 6,000 IU per day. There were no observable events in the literature even at 10,000 IU per day, but to be safe, it was set at 4,000 IU.

Also, I’ve never seen a vitamin D supplement without a recommended amount to take. On the other hand, I’ve never seen a warning about consuming excess pharmaceuticals on the prescription bottles either. Buried in the flyer that comes with the prescription, yes, but not on the label.

The Bottom Line

Whether you’re 19 or 89, you should base your vitamin D intake on a vitamin D blood test. Vitamin D is not innocuous; take too much and it can be harmful. But there is nothing to fear in taking it in reasonable amounts to benefit your bones and your immune system. Physicians have prescribed 50,000 IU once a week for months to help people who need to raise their serum 25-hydroxyvitamin D (25OHD) levels. If it were not safe, it wouldn’t be used in that fashion. It also means you shouldn’t take it at a high level without guidance.

Again, base your vitamin D intake on the blood test and know why you take the amount of vitamin D you take. No reason to get extreme; just be reasonable.

The special pricing on the Real-Life Detox ebook ends tomorrow. The clocks change tonight, so it’s a good time to change your body with some spring cleaning.

What are you prepared to do today?

        Dr. Chet

Reference: Institute of Medicine (US) Committee to Review Dietary Reference Intakes for Vitamin D and Calcium; Washington (DC): National Academies Press (US); 2011.

Vitamin D: Cautionary News

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Every once in a while, news on the suspected abuse of a dietary supplement makes headlines; such was the case when I read my news feed this past weekend. An assistant coroner in Surrey, U.K., declared the cause of death for an 89-year-old man was excessive calcium build-up due to high levels of vitamin D supplements. He was hospitalized in May 2023 and died 10 days later. The coroner’s report just released cited his vitamin D intake as a contributor to his death.

When more vitamin D is taken in than the body can process, the possibility exists that it can release calcium from the bones, which can then settle in the coronary arteries and kidneys. Heart and kidney failure were the actual causes of death. The coroner criticized the labeling on the supplement bottles because it contained no warnings. When queried, representatives of several U.S. medical schools talked about the “dangers” of exceeding the 4,000 IU (100 mcg) upper limit for vitamin D.

I think the man’s death was tragic, but I think everyone needs to take a deep breath. There are several issues related to this situation that weren’t talked about, and I’ll cover those in the Saturday Memo.

Remember, the Real-Life Detox ebook is on sale through Sunday evening. Laptop, tablet, or smart phone, you can spring clean your liver to get ready for the summer.

What are you prepared to do today?

        Dr. Chet

References:
1. https://www.express.co.uk/life-style/health/1872500/supplements-vitamin-d-warning-man-dies-overdose
2. https://www.ncbi.nlm.nih.gov/books/NBK56058/

Research Update on Vitamin D

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Vitamin D supplementation always seems to be in the health news; one day it’s beneficial, the next not so much. One of the problems is that many studies are observational studies. They take a large group of subjects, such as the Nurses Health Study, use food frequency questionnaires to assess vitamin D intake, and report on bone health and other outcomes over time. That has serious limitations in my opinion, not least among them the reliance on food frequency questionnaires, which have been proven inaccurate. Do you remember what you had for dinner last week or the week before? Neither do I.

In a recently published study, researchers did a meta-analysis on vitamin D in observational studies, randomized controlled trials (RCT) on vitamin D supplementation alone, and RCT on vitamin D plus calcium supplementation. The outcomes were all fractures and hip fractures, and the subjects were mostly older than 65.

While there were issues in just about every observational and RCT of some sort, the analysis of each type of trial combined was that vitamin D supplementation did not have a significant effect on the rate of fractures. However, when vitamin D supplementation was combined with vitamin D and calcium supplementation, there was a 6% decrease in all fractures and a 16% decrease in hip fractures over an average of six years. The amounts of vitamin D used were 400 to 800 IU and 1000 to 1200 mg of calcium per day.

While there’s more research to go including the completion of some of randomized controlled trials used in the analysis, take vitamin D and calcium together to reduce the risk of hip fractures and other broken bones. Better together seems to be more effective than overdoing it on a single nutrient.

What are you prepared to do today?

        Dr. Chet

Reference: JAMA Network Open. 2019;2(12):e1917789.

Food Is Better Than Supplements, But …

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Getting your nutrients from food by eating a healthy diet is the most desirable way of getting vitamins, minerals, and phytonutrients. Period. If we could all do it, no question that’s the best way. But you and I don’t live in some fantasy world. We’re busy. We don’t always have enough time to shop and cook healthy meals. Dietary supplements have helped fill the nutrition gap.

What should we think about this latest research? Should we stop taking supplements, especially calcium? Before I give you my opinion, I want to tell you that I emailed the corresponding author of the paper, a brilliant woman and a talented researcher. I had two questions about the study. She answered me the same evening—Saturday night before Easter. That I got such quick reply was remarkable; I’m still waiting for answers from other researchers I contacted months ago.

The first question I asked was a basic one: what was the mortality rate of the subjects in the study compared with the national cancer mortality rate? The national mortality rate is 156 deaths per 100,000 people per year. That works out to 1.6 people per 1,000. The rate in the study was about 3 people per 1,000. She replied that the study results are not directly comparable for complicated reasons.

But here’s something that can be directly compared. A 62% increase in cancer mortality would be transferable to national statistics because that’s the idea: to generalize to the entire population. A 62% increase means that 2.5 people per 1,000 would die from cancer in a given year instead of 1.6. When applied to the entire population that could be a lot of people, but it applies only to those who took over 1,000 mg of calcium per day.

The other question I asked was whether they had data on how long the people were taking the supplements; NHANES asked about the 30 days prior and recorded the prior 24 hours. How long were they taking the supplements? Weeks? Months? Years? Decades? That might have made some difference. The data were collected in the questionnaires used for two of the cycles that I examined, but that data was not used in the analysis.


The Bottom Line

I think we should eat the best diet we can. I also think we should use quality dietary supplements to complement our diet. This study was an exercise in statistics more than nutrition. It can tell us the statistical outcomes of the people in the study, but it can’t really be used to tell us anything about what we should do as individuals.

Not every person who took a higher amount of calcium died from cancer. On top of that, if supplementation did have a significant negative impact on our health, it stands to reason there would have been more negative results than just for calcium. Because the research questions were fitted to the available data, there’s just too much we don’t know about factors that can influence the results.

Another good question the study didn’t ask is why people were taking calcium. For instance, a woman with osteoporosis may take calcium for better bone health. Did those women have fewer broken bones with supplementation? If so, that might be worth any higher risk that exists. As with any nutritional intervention, it’s important to weigh the pros and cons. If you’re concerned, talk to your healthcare professional about what you should do; they know you and your health status and can help you make the right choices.

Supplement confusion is a good reason to get a copy of my new CD Supplementing Your Diet. Check out why at drchet.com.

What are you prepared to do today?

        Dr. Chet

Reference: Ann Intern Med. doi:10.7326/M18-2478.

Food vs. Supplements: A Closer Look

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There’s no question National Health and Nutrition Examination Survey (NHANES) has done the best job of collecting data on nutritional intake in large-scale studies. I’ve applauded it in the past, and I’m not going to change now just because there’s an NHANES-based paper that critiques the use of supplements. NHANES data were used by one of the co-authors of the current research paper we’re examining; in that study, they demonstrated regular use of a multivitamin-multimineral can compensate for deficiencies in our diet.

What could explain the same data showing potential benefits and hazards of supplements? Two reasons in my opinion. First, the research questions were not part of the original study; that’s supported by the fact that the lead author would have been six or seven years old when data collection began.

Imagine you apply for a loan. You’d give the bank all kinds of financial data: your total earnings, where you work, what you owe, and so on. Then imagine that researchers take all that very accurate data and estimate your hourly wage. They could be right on the money or way off, because they don’t know how many hours you worked; that wasn’t one of the questions. It’s the same with the data in this study; the researchers can make a great guess from the data they have, but the question they’re trying to answer wasn’t one of the original questions asked so their guess may be very far from correct. That happens often in these retrospective studies.

Second, the bulk of the researchers were experts in statistics and epidemiology. The statistical analysis accounted for 11 factors to numerically make the data comparable. We can’t really know what that does to modify the data instead of collecting data on actual variables.

Still worried? I’ll finish this up on Saturday.

What are you prepared to do today?

        Dr. Chet

Reference: Ann Intern Med. doi:10.7326/M18-2478.

Food vs. Supplements

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Last week, the health headlines blared that nutrients from foods were better than nutrients from supplements—specifically that excess calcium from supplements was associated with an increased risk of dying from cancer. That will get your attention if you take supplemental calcium, especially if you’re taking calcium because your physician told you to take it because you have osteopenia or osteoporosis. Let’s take a closer look at this study published in the Annals of Internal Medicine.

Researchers examined data collected for the National Health and Nutrition Examination Survey (NHANES) on food intake and supplement use. NHANES data are now collected every two years, so they selected six consecutive cycles and tracked the all-cause mortality from subjects in those data. They found that in over 30,000 adults over 20 years of age tracked for six years, there were 3,613 deaths with 805 from cancer.

The researchers then examined the food intake and supplement use of the subjects from the prior 30 days of data collection with mortality data. That’s where they discovered that in the subjects who died from cancer, there was a 62% greater risk if they took more than 1,000 mg of supplemental calcium per day. The overall conclusion was that nutrients from foods are better than nutrients from supplements; in addition, some supplements may be hazardous.

Should you start chucking out your calcium supplements? We’ll take a closer look at this study the rest of this week.

What are you prepared to do today?

        Dr. Chet

Reference: Ann Intern Med. doi:10.7326/M18-2478.

Do Calcium Supplements Harm Your Heart?

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Over the past few years, concern has grown about the relationship between heart disease and calcium intake. A couple of studies have shown a possible association between calcium intake and cardiovascular disease. In an article also published this month in the Journal of Women’s Health (1), two clinicians reported on a number of studies including one that examined calcium intake and heart disease. Their purpose was to update clinical guidelines for physicians and internists who regularly treat women and heart disease.

They selected a study that included a meta-analysis of studies on calcium intake from food and supplements (2). You know my position on meta-analysis and its overuse and limitations, but in this case, the researchers wanted to establish positions for both the National Osteoporosis Foundation and the American Society for Preventive Cardiology on calcium intake and heart disease. I think the use of this statistical method was warranted.

After an exhaustive review of the studies and re-analysis of the data, researchers found that calcium intake, from either food or supplements, at levels up to 2,000–2,500 mg per day are not associated with CVD risks in generally healthy adults. Although they found a few trials that reported increased risks with higher calcium intake, the risks were small and not considered to be clinically important even though they were statistically significant. The results applied to women and men.

At this point, with data from tens of thousands of subject, taking calcium from food or supplements will not harm your heart if you’re healthy. Does that mean you should limit calcium if you’re not healthy? No. There just isn’t sufficient data to know. In my opinion, if you take 800–1,000 mg of calcium per day, I think you’ll be fine but you should always check with your physician. You need calcium for many reasons, including bone and blood health and conducting signals between nerves. Especially if you don’t consume a lot of dairy, take your calcium supplement.

What are you prepared to do today?

Dr. Chet

 

References:
1. J Women’s Health DOI: 10.1089/jwh.2018.6932
2. Ann Intern Med 2016;165:856–866.

Why Nutrition Is a Process

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A celebrity doctor who specializes in cancer treatment said something that caught my attention, and it goes to this question: why are some people cured by specific treatments while others don’t respond at all? In his opinion, it’s because the cancer creates a new system in the body that competes with the other systems.

The new system may be different in each body once the cancer is established, which could mean that everyone really requires an individual approach. A systems approach would be necessary only if the cancer gets too established; early diagnosis can use treatments that work in most people. Late diagnosis means the cancer has established a system with strengths and weaknesses that are unknown. But the systems approach isn’t limited to cancer.

What’s a Systems Approach?

A systems approach is simply this: we attempt to reach a goal by looking at the interactive nature and interdependence of all the factors in an entity.

Here’s an analogy: you flip the switch for the light in your kitchen, but the light doesn’t go on. What could be wrong? The light won’t work if:

  • Your bulb is burned out
  • Your circuit breaker needs to be reset
  • An electrical outlet somewhere has a tripped GFCI
  • Your switch has gone bad
  • A wire is loose in your light fixture
  • The power is out to your whole house

Turning on a light is easy—my grandson Riley is very good at it and he’s not even three. But if it’s not working, you have to look at each element of the system to find the problem and get the kitchen light back on.

How Vitamin D is Part of Your Bone Health System

While osteoporosis or weight gain doesn’t create a new system like cancer does, there are numerous steps in both processes. On top of that, if we’ve been on the path to bone loss or weight gain, there may be changes in normal metabolism that have to be overcome.

Let me explain using vitamin D for bone health. Whether we make vitamin D in our skin, get it from food, or take it in supplement form, it has to be processed by the liver to become the active form to promote bone growth. If there’s a defect in getting the raw vitamin D from food or a supplement into the bloodstream and on to the liver, not enough vitamin D would be made into the active form. Or there may be a defect in the processing of the raw vitamin D once it gets to the liver. Or there may a defect in the receptor for the active vitamin D on the target tissue. I could go on and on about where issues could occur, but I hope you get the point. Right now, we have no idea where the issue might be for the use of vitamin D in an individual just as we don’t know where the weak point of a cancer system might be and thus where we should attack.

Do we quit? No. We simply use a systems approach—we look at every step necessary to reach our goal and what we can do at each step. We begin with taking vitamin D for a specific period of time. We then get re-tested, most likely a bone density scan. If there’s growth, great. If there’s not, then we either add more D or add calcium or switch to a different form of calcium. Then retest. If that doesn’t work we can add vitamin C or glucosamine, both critical to the manufacture of connective tissue. There are other factors such as smoking and exercise that also impact bone growth. We systematically add new variables or add more of some that we’re already doing. Might this take a long time? Yes. Would we have to pay attention? Yes. But is it a natural approach to complicated conditions? Again, yes. No matter what the condition, if you’re going to try to deal with it nutritionally, that’s the approach you’ll have to take. You have to find what works for you.

The Bottom Line on Vitamin D

The systems approach goes a long way to explain why some people benefitted from vitamin D and calcium to prevent fractures and others did not. The only fact the meta-analysis study proves is that vitamin D and calcium supplementation don’t work for everyone. The key is to move on to the next approach; it may be different supplements or it may even be a medication. More options must be tried until a solution is found for each individual.

Over time, I’m going to continue to explore this concept of a systems approach to nutrition. I have no idea where it will lead, but it’s worth spending more time thinking and researching it.

What are you prepared to do today?

Dr. Chet

 

Reference: JAMA. 2017;318(24):2466-2482. doi:10.1001/jama.2017.19344.

 

You Actually Have to Take the Supplements

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The authors of the study on calcium and vitamin D supplementation as they relate to fractures were all orthopedic surgeons, as stated in the paper. They had no known training in nutrition. Maybe not statistics either.

When you perform a meta-analysis, each research study included is given a weight in the form of a percentage, which indicates how much it contributed to the outcome. Not all studies should contribute equally; that helps to eliminate the bias of a tremendous benefit in a very small study versus a large study with no benefit. They didn’t seem to read something in three studies that contributed close to 90% of the analysis (2-4): the authors of those papers said that the reduction in fractures did occur, or at least bone was restored, when the subjects took over 80% of the doses of calcium and vitamin D they were supposed to take. The problem: average compliance was around 50%.

What these surgeons could have done was tease out the data on those subjects who were compliant and analyzed that data. What they might have had were results that demonstrated that in order to get a benefit, subjects had to take the supplements regularly. That would have been meaningful. Instead, inexperience or ignorance left us with headlines but little else.

Still, there are some questions that were raised in my mind and I’ll cover them on Saturday. But one thing won’t change: if you’re going to take supplements of any kind, you’ve got to actually take them if you want a benefit.

What are you prepared to do today?

Dr. Chet

 

References:
1. JAMA. 2017;318(24):2466-2482. doi:10.1001/jama.2017.19344.
2. Lancet. 2005;365(9471): 1621-1628.
3. Arch Intern Med. 2006;166(8):869-875.
4. Am J Med. 2006;119(9):777-785.

 

Are Vitamin D and Calcium Still Worth Taking?

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Maybe you recently read a headline that went something like this: “Vitamin D and Calcium Do Not Prevent Fractures.” Many headlines were much worse. Over this past weekend I read the research paper published in JAMA. Is it real? Should you not bother taking your calcium and vitamin D to protect your bones? No—keep taking them. But it does give me an opportunity to talk about some of the issues surrounding these types of papers as well as the complexity of nutrition for our health. That’s our topic this week.

The study was a meta-analysis of studies that examined the relationship between the risk of fractures in elderly populations and supplementation with calcium, vitamin D, and both supplements together. After a rigorous database search, 33 randomized controlled trials were included in the meta-analysis. Some studies lasted several months, and some lasted several years. The amounts of calcium and vitamin D in the supplements varied in every study. After analysis, the researchers determined that neither calcium nor vitamin D nor the combination of both reduced the rate of fractures when compared to placebo. That led to their conclusions.

This was a mess as you probably guessed with differing quantities and lengths of the trials. What bothered me most was that if they really understood nutrition as well as the results of the studies they included, they could have done something special. I’ll cover that on Thursday.

What are you prepared to do today?

Dr. Chet

 

Reference: JAMA. 2017;318(24):2466-2482. doi:10.1001/jama.2017.19344.