Tuesday, May 17, 2011

Recommended Supplements for Bone Health

Recently, my husband, son and I visited my mother-in-law, Maggie, in Washington, DC.  We had a wonderful time.  During our conversations, I mentioned I was writing a blog about alternative health and nutrition.  At that point, Maggie asked me what I thought about her Calcium/Vitamin D supplement.  I’ve read a bit recently about Calcium supplementation being correlated with calcification of the arteries and heart disease.  I have also heard that Vitamin K2 is useful for bone re-mineralization and the avoidance of bone fractures in the elderly.
So, I wanted to look a little deeper into the subject to figure out what would be the best course of action for Maggie in regards to supplementing to avoid bone fractures and osteoporosis.

Many of my favorite, trusted bloggers have written about the subject, so this post is going to more or less review their posts and string together their thoughts and research in a way that is hopefully meaningful and leads to a recommended supplemental regimen for Maggie.  Disclaimer: I am FAR from a professional or expert in this area, and these are just my humble recommendations, based on the information I have found online from what I believe are trusted sources.  Okay, here we go:

Key Point:  I was listening to Dr. John Neustadt, an expert on bone health, on the Underground Wellness podcast.  He makes a great point that whatever treatment you use, you should be looking for a treatment (or supplement routine) that reduces bone fractures.  Bone Density is only 44% effective and predicting bone fractures.  So, we should look at the research through the lense of bone fracture risk reduction instead of merely building bone density.

Calcium Supplementation –Is it prudent? Is it safe? 
Here’s an interesting quote from the Americam Journal of Clinical Nutrition (found here: http://www.ajcn.org/content/77/2/504.long): “Calcium has been the focus of nutritional research for the prevention of postmenopausal osteoporosis as many clinical trials of calcium supplementation have found that it can indeed reduce bone loss and lower the risk of bone fractures.  However, the trials often include a simultaneous treatment with vitamin D, which makes it difficult to attribute the benefits to calcium alone. Also, the bone density increase found during the first year or two of calcium supplementation may not substantially increase in the long term. In contrast to most clinical data, most observational studies did not find a significant association between calcium intake and fracture risk or bone loss.”  So, it seems there’s not a whole lot of evidence showing that calcium alone prevents fractures or bone loss.

Additionally, there have been several recent studies linking calcium supplementation to heart disease.  One recent study, published in The British Medical Journal, was titled Calcium supplements with or without vitamin D and risk of cardiovascular events: reanalysis of the Women’s Health Initiative limited access dataset and meta-analysis  (found here:  http://www.bmj.com/content/342/bmj.d2040.full).  In this study, researchers reanalyzed the data from the Women’s Health Initiative study, a 7-year trial in which 36,282 postmenopausal women were randomly assigned to calcium and vitamin D or placebo.  They found Women taking calcium supplements with or without vitamin D demonstrated a modest increase in the risk of cardiovascular events including myocardial infarction, stroke, and death from coronary heart disease.

Unfortunately, there really hasn’t been a clinical study to date that has looked at calcium’s affect on heart health.  The studies that have been done have been primarily observational, which means the results can’t be completely trusted.  After all, correlation does not prove causation.  It does send up a red flag, though.

My recommendation:  As long as you are not deficient in calcium (if you don’t know, get your levels tested), it would be best practice to get your calcium from food. Green, leafy vegetables are a great source.  Have a salad every day.  Grass-fed, raw dairy is also a good source.  My suggestion would be to eat lots of cultured, raw dairy, like raw cheese and yogurt.  These aren’t available at conventional grocery stores.  You can get them over the internet, at farmer’s markets or at health food stores, like Whole Foods. 

Now, if you were deficient in calcium, I would look for a calcium supplement that is derived from whole foods.  It looks like most of the whole foods calcium supplements (like those from Garden of Life and New Chapter) also include other nutrients (such as Vitamin D and Magnesium). So, if you need to supplement calcium, you will need to limit your other supplements, so that you are not getting too much of any one nutrient).

Another source of raw calcium is Coral Legend (found here: http://www.radiantlifecatalog.com/product/CORAL-LEGEND-MINERAL-POWDER/salts-minerals), which contains a highly absorbable form of calcium with magnesium.  If you decide to take calcium and are planning to use other supplements (as per my recommendation) for Vitamins D and K, this is a good way to make sure you aren’t getting too much of the other nutrients.

Vitamin D – It’s probably a good idea to supplement with Vitamin D3, but again you should get your levels tested.   Here’s some information from one of the blogs I read regularly, The Healthy Skeptic (found here: http://thehealthyskeptic.org/9-steps-to-perfect-health-4-supplement-wisely):

“Much has been written about the need for and benefits of vitamin D supplementation over the past several years and with good reason. Its absolutely critical for health, and up to 50% of Americans are deficient.

We can get vitamin D from two sources: food, and sunshine. Seafood is the only significant source of vitamin D, but youd still have to eat a lot of it to get enough. 8-9 ounces of herring provides about 2,000 IU of vitamin D, which is a minimum daily requirement for most people to maintain adequate blood levels.

Sunlight converts a precursor called 7-dehydro-cholesterol in our skin to vitamin D3. This D3, along with the D3 we get from food, gets converted by the liver into 25-hyrdroxy-vitamin D (25D), which is what typically gets measured when you have a vitamin D test. The optimal 25D level is somewhere between 35 and 50 ng/mL.

What about sunlight? Well, in summer mid-day sun with pale skin, 30 minutes of direct sunlight will produce 10-20,000 IU of vitamin D. But this is a best-case scenario. With darker skin, or different times of year, or buildings that block the sunlight, or increased time spent indoors, we wont be producing that much. Its also true that aging, overweight and inflammation reduce our conversion of sunlight to vitamin D. This is why sunlight alone isnt normally a sufficient source of vitamin D.

With this in mind, most people should supplement with D. The amount needed to maintain blood levels of 35-50 ng/mL varies depending on some of the factors Ive listed above, but in my clinical experience its usually somewhere between 2,000 5,000 IU. With vitamin D, its important to test your levels, begin supplementation, and then re-test a few months later to determine the correct maintenance dose.”

My recommendation:  Supplement with cod liver oil (CLO) to get enough Vitamin D.  It’s a whole food supplement, and also provides Omega-3 fatty acids, which as we know promote cardiovascular health and are anti-inflammatory.  CLO also provides Vitamin A.  I was listening to a recent podcast with Primal Body Primal Mind podcast (found here: http://itunes.apple.com/podcast/primal-body-primal-mind-radio/id385416862) about the importance of Vitamin A to avoid Vitamin D toxicity.  She mentioned that for every receptor for Vitamin D, there is a receptor for Vitamin A.  The two work together.  The nice thing about CLO is that it provides both nutrients.  The best version of CLO, from what I can gather online, is Green Pastures (found here: http://www.greenpasture.org/public/Products/ButterCodLiverBlend/index.cfm).  Note: this is actually the CLO combo with High Vitamin Butter Oil (more on that in the following section’s recommendations).

Vitamin K2 (MK-4)
Theres a lot of great information on the blogs I read regarding Vitamin K2.  Heres what the Healthy Skeptic says (found here http://thehealthyskeptic.org/9-steps-to-perfect-health-4-supplement-wisely):  Vitamin K2 may be the most important vitamin most people have never heard of. Its needed to activate proteins and it also regulates calcium metabolism (keeping it in the bones and teeth where it belongs, and out of the soft tissue where it doesnt belong). Elevated blood calcium significantly increases the risk of cardiovascular disease (CVD), which explains why vitamin K2 has been shown to prevent atherosclerosis and heart attacks (http://www.ncbi.nlm.nih.gov/pubmed/18722618). It also strengthens bones (http://www.ncbi.nlm.nih.gov/pubmed/16801507)
Unfortunately, many (if not most) of Americans are deficient in vitamin K2. Its important to point out that vitamin K2 is not the same as vitamin K1, which is found in green, leafy vegetables like kale and collards. Some K1 is converted into K2 in our bodies, but that conversion is inefficient in humans. It is efficient, however, in ruminant animals which is why grass-fed dairy is the most convenient source of vitamin K2 in the diet. This is only true in animals raised on pasture, because it is eating the K1-rich grass that allows them to convert it into K2.
Most people should aim for at least 100 mcg/d from a combination of food and supplements. If you eat a large amount of cheese from grass-fed cows and pastured egg yolks, you may be able to get this amount from food alone. 100 g of hard cheese contains 67 mcg, and 6 pastured egg yolks contain about 32 mcg. Otherwise, supplementation is probably beneficial. I recommend a dosage of 1 mg/d in the MK-4 form, which is the form of vitamin K2 found in pastured dairy and the one shown to have the most benefit in clinical studies.
The Whole Health Source blog had a very interesting post that reviewed an animal study (found here: http://www.ncbi.nlm.nih.gov/pubmed/17138823) that showed Vitamin K2 MK-4 reversed arterial calcification in rats.  His post can be found here: http://wholehealthsource.blogspot.com/2008/11/can-vitamin-k2-reverse-arterial.html).  The Whole Health Source did another blog post of this nutrient found here:  http://wholehealthsource.blogspot.com/2008/06/vitamin-k2-menatetrenone-mk-4.html. 

On the website for Osteo-K (a Vitamin K2 MK-4 supplement), the following studies were listed, showing links between MK-4 supplementation and reduction in fractures:
  1. Booth SL, Tucker KL, Chen H, et al. Dietary vitamin K intakes are associated with hip fracture but not with bone mineral density in elderly men and women. Am J Clin Nutr. 2000;71(5):1201-1208.
  2. Cockayne S, Adamson J, Lanham-New S, Shearer MJ, Gilbody S, Torgerson DJ. Vitamin K and the Prevention of Fractures: Systematic Review and Meta-analysis of Randomized Controlled Trials. Arch Intern Med. 2006;166(12):1256-1261.
  3. Kaneki M, Hosoi T, Ouchi Y, Orimo H. Pleiotropic actions of vitamin K: protector of bone health and beyond? Nutrition. 2006;22(7-8):845-852.
  4. Sato Y, Kanoko T, Satoh K, Iwamoto J. Menatetrenone and vitamin D2 with calcium supplements prevent nonvertebral fracture in elderly women with Alzheimer's disease. Bone. 2005;36(1):61-68.
  5. Shiraki M, Shiraki Y, Aoki C, Miura M. Vitamin K2 (Menatetrenone) Effectively Prevents Fractures and Sustains Lumbar Bone Mineral Density in Osteoporosis. Journal of Bone and Mineral Research. 2000;15(3):515-522.
Richard Nikoley, at Free the Animal, also explains the benefits of MK-4 through a historical lens, by looking at the work of Weston A. Price.  If you dont know who Weston A. Price is, google him!  It will be work the effort.  In short, he was a dentist who traveled the world studying traditional populations to discover the common threads in their diets that kept them healthy and free of tooth decay.  He found several commonalities amongst these different populations, one of which he called Activator X. 
Heres Richards quote:  “Weston Price was primary interested in Activator X because of its ability to control dental caries. By studying the remains of human skeletons from past eras, he estimated that there had been more dental caries in the preceding hundred years than there had been in any previous thousand-year period and suggested that Activator X was a key substance that people of the past obtained but that modern nutrition did not adequately provide. Price used the combination of high-vitamin cod liver oil and high-Activator X butter oil as the cornerstone of his protocol for reversing dental caries. This protocol not only stopped the progression of tooth decay, but completely reversed it without the need for oral surgery by causing the dentin to grow and re-mineralize, sealing what were once active caries with a glassy finish. One 14-year-old girl completely healed 42 open cavities in 24 teeth by taking capsules of the high-vitamin cod liver oil and Activator X concentrate three times a day for seven months.” (found here: http://freetheanimal.com/2008/11/vitamin-k2-menatetrenone-mk-4.html).
My recommendation:  Supplement with Vitamin K2 (MK-4).  I do this and feel it is even more beneficial for those who are fighting osteoporosis or are in danger or bone fractures.  There seems to be more than ample evidence that this nutrient is essential to bone health.  My supplement recommendation is to supplement with the combined CLO with high vitamin butter oil (Weston A. Price’s Activator X).  Again, this is a whole foods supplement that will be superior to taking an isolated, synthetic supplement.  Green Pastures makes this supplement and it can be found here: http://www.greenpasture.org/public/Products/ButterCodLiverBlend/index.cfm). 
There are other supplements, such as Magnesium and Boron that are likely also useful for bone health.  I take a daily Magnesium supplement called Natural Calm, myself.  I didn’t really have time to look into these benefits/risk to these supplements, so I really don’t have an opinion.

So, Maggie, my recommendation would be to supplement with the Cod Liver Oil/High Vitamin Butter Oil combo.  It comes in pill form for about $25 for month’s supply (for the recommended dosage).  It’s more expensive than synthetic vitamins, and it is more difficult to procure (most likely, it will have to be ordered online, which I can do for you), but it will be more bioavailable (i.e. better absorbed by your body), and doesn’t separate nutrients, which is key since the (1) work synergistically and (2) prevent toxicity, which can occur by taking too much of one supplement and not enough of another.  This single supplement will supply you with Vitamin D, Vitamin K2 (MK-4), Vitamin A (not necessary for bone health, but has other benefits), Omega-3 fats, among other nutrients.  I would also recommend getting daily sunshine when possible, and getting both your Vitamin D and Calcium levels tested. 

If you find you are deficient in calcium, I would consider supplementing with Coral Legend (found here: http://www.radiantlifecatalog.com/product/CORAL-LEGEND-MINERAL-POWDER/salts-minerals), or with raw calcium.

Sorry for such a long post.  I hope it was thorough and made sense.

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