Folic Acid vs. Folate

Written by Dr. Steve Chaney on . Posted in current health articles, folic acid vs. folate, Health Current Events

Are Supplement Manufacturers Trying to Mislead You?

Author: Dr. Stephen Chaney

folic acid vs. folate questionThere has been much confusion on folic acid vs. folate.  For example, I recently received this question from a reader:

“I have gotten so much clarification about folic acid from your video – thank you!
But I have another question I was hoping you could answer.

When a supplement label states there is “folate” rather than “folic acid”, is there really a difference between the two? I hear women telling each other to only use the one that says folate because it’s made from food. And folic acid isn’t. These women are also paying more money for these products because of this. Is this true? (And I’m not talking about tetrahydrafolate, either)
I’ve been told by one manufacturer that they label it as folic acid, but they know other companies who use the exact same source of folic acid.  Still,  they put folate on their label, possibly to avoid controversy.
Are these women being duped? Should they be asking the manufacturer certain questions for clarification?”

The video, this reader is referring to is my “The Truth About Methyl Folate” video in which I debunk the many myths about methyl folate circulating on the internet, and, unfortunately, repeated by some doctors.

However, the reader is correct. I did not address the folic acid vs. folate nomenclature in that video. I will attempt to clarify it in this article.

Folic Acid vs. Folate

A Rose By Any Other Name

roseI call this section “A Rose By Any Other Name” from the famous Shakespeare quote from Romeo and Juliet “A rose by any other names would smell as sweet”.

Biochemists and nutritionists use the terms folic acid and folate interchangeably. There is a sound chemical rationale for that.

Folic acid has a glutamic acid residue on one end. Thus, folic acid is what chemists refer to as an organic acid, specifically a carboxylic acid. Under acidic conditions the appropriate suffix for an organic acid is “ic”. However, under neutral or alkaline conditions, organic acids lose their protons. Once that happens, the appropriate suffix is “ate”.

The exact pH of vitamin pills may vary from brand to brand. In our body our stomach is acidic, our intestines are alkaline, and our blood and cells are normally near neutral. Thus, vitamin B9 could correctly be labeled either folic acid or folate in supplements. It will be folic acid in our stomach and will be folate in our intestines, bloodstream, and cells.  Beginning to see the difference between folic acid vs. folate?

The bottom line is that nobody is trying to trick you by using the term folate for the vitamin B9 on their supplement label. Furthermore, whether the label says folic acid or folate, the actual vitamin B9 will be in both the folic acid and folate form as it travels through your body.

In answer to your other question, since folic acid and folate are two names for the same molecule, folate is not more natural than folic acid. If someone is charging you extra because they use the term folate on their label, they are ripping you off.

 

What About Tetrahydrofolate?

uderstanding folic acid vs. folateThe person who sent me the question also asked about tetrahydrofolates.  Here the story gets a bit murkier.  As folic acid or folate enters our cells, three things immediately happen:

  • It is reduced to tetrahydrofolate. That terminology simply means that 4 hydrogens have been added to the molecule.
  • A string of glutamic acid residues is added. That traps it inside the cells.
  • It is converted to a half dozen different derivatives that play important metabolic roles in the cell. N5-methyltetrahydrofolate (commonly referred to as methyl folate) is one of these metabolically active compounds.

This is where it gets confusing. Nutritionists also refer to all of these tetrahydrofolate derivatives as folates. My guess is that years ago some genius must have decided that the term tetrahydrofolate was too long and complicated for the general public.

In my view lumping everything together under the term folate has turned out to be more confusing in the long run. However, I do have the advantage of hindsight.  It’s easy to point out mistakes after they are made.

However, this is where all of the confusion arises.  It’s because the term folate can mean so many different things.  Here are a few fast facts to help clarify the confusion.

  • Folates in food are in the tetrahydrofolate form. Tetrahydrofolate in foods is, in fact, more natural than folic acid or folate in supplements. However, tetrahydrofolates in foods are utilized only about half as well as folic acid or folate in supplements. In addition, most of us don’t eat enough high-folate foods.
  • In contrast, tetrahydrofolate in a supplement is not more natural than folic acid. That’s because:
  • It would require one cup of lentils or two cups of spinach to provide the RDA level of tetrahydrofolate in a single vitamin tablet. That’s just one tablet.  You do the math!  If someone tells you that the folate in their supplement came from foods, they will lie to you about other things as well.
  • In fact, the tetrahydrofolate found in supplements is chemically synthesized from folic acid. It can never be more natural than folic acid.
  • Supplements containing tetrahydrofolate are no better utilized than supplements containing folic acid when you measure their ability to increase cellular tetrahydrofolate levels (the only measure that really matters).

The bottom line is that even if folate on the label were to refer to tetrahydrofolate, it is not from food.  It is not more natural than folic acid.  It is not better utilized than folic acid.  If someone is charging you a higher price for that supplement, they are ripping you off.

 

Debunking The Methyl Folate Myths

mythsMethyl folate has become an internet sensation.  If you believe all the hype, everyone should be using supplements containing methyl folate rather than folic acid.  In fact, some of the claims made by manufacturers who sell methyl folate supplements are downright deceptive.

Unfortunately, there are even medical doctors touting the wonders of methyl folate and offering all sorts of plausible sounding biochemical explanations about why it is superior to folic acid.  My take on that is that I try not to practice medicine when I write my articles.  I have neither the training nor the degree to do that.  In turn, I would ask medical doctors to stop trying to practice biochemistry.

As I said at the beginning of this article, I have produced a video, “The Truth About Methyl Folate,” in which I debunk all the many methyl folate myths circulating on the internet. If you would like the “Cliff Notes” version, here it is:

  • Supplements containing methyl folate do not get their methyl folate from foods.
  • Methyl folate in supplements is chemically synthesized and is not more natural than folic acid.
  • Folic acid and methyl folate in supplements are equally well utilized by the body, even in individuals with a MTHFR deficiency.
  • Excess folic acid does not cause cancer.

If you would like the science and the references behind those statements, I invite you to view my video.
metho folate
I hope you now understand folic acid vs. folates.  If not, please feel free to reach out to me.

 

The Bottom Line

  • A reader recently asked me to clear up the confusion about why the terms folic acid vs. folate are used interchangeably on supplement labels to describe vitamin B9.
  • That terminology is based on simple chemistry.  Folic acid and folate are two names for the same molecule. Under acidic conditions, it is called folic acid. Under neutral or alkaline conditions, it is called folate.
  • Since folic acid and folate are two names for the same molecule, folate is not more natural than folic acid.  If someone is charging you extra because they use the term folate on their label, they are ripping you off.
  • In the cell folate is reduced to tetrahydrofolate and a number of metabolically active derivatives of tetrahydrofolate are formed. Unfortunately, these compounds are also referred to as folates. This terminology has a historical basis rather than a chemical basis and is confusing.
  • If you see the term tetrahydrofolate on your supplement label,  you need to know that it is not from food.  It is not more natural than folic acid.  It is not better utilized than folic acid.  If someone is charging you a higher price for that supplement, they are also ripping you off.
  • I have produced a video called “The Truth About Methyl Folate” to debunk the many methyl folate myths on the internet. In the article above, you will find the “Cliff Notes” version of the video.

 

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 There Diets to Fight Depression In Women

Written by Dr. Steve Chaney on . Posted in Diets to Fight Depression, Health Current Events

A Story of 6 Blind Men And An Elephant

Author: Dr. Stephen Chaney

 

 

6 blind men and a elephantAre there diets to fight depression in women?  This week’s health tip reminds me of the story of 6 blind men and an elephant. You probably remember the story. One blind man grabbed a leg and declared that an elephant is like a tree trunk. Another blind man grabbed the tail and declared that an elephant was like a rope – and so it went. Each blind man had a different version of reality, but none of them really knew what an elephant was like.

Sometimes science is like that. Every scientific study is designed to test a specific hypothesis, and sometimes we scientists can become limited by the hypothesis we are testing. We only see what we are looking for. We become like the blind men trying to figure out what an elephant really is.

That thought came to mind recently when one study claimed that an anti-inflammatory diet decreased the risk of depression by 26% in women, and another claimed that increased flavonoid intake was the secret to decreasing depression in women. Of course, both of those reports came on the heels of another study a few months ago claiming that a Mediterranean diet was the secret to decreasing depression.

If all of this sounds confusing, keep that image of the blind men and the elephant in your mind for a while. I’m going to come back to the elephant later, but let me start by evaluating the merits of the two most recent studies which claim there are diets to fight depression in women.

How Were These Studies Designed?

diets to fight depressionThe first study (Shivappa et al, British Journal of Nutrition, doi:10.1017/S0007114516002853, 2016)  was designed to test the association between the anti-inflammatory potential of their diets and the risk of depression in middle-aged Australian women. The study followed 6,438 women with an average age of 52 for 12 years.

Self-administered surveys were sent to the participants every 2-3 years (most participants completed 5 surveys during the study). A Dietary Inflammation Index (DII) was calculated based on the food frequency portion of the surveys. Depression scores were calculated based on their answers to 10 questions from a well established depression rating system.

This was a well designed study and the results were fairly straight forward. Those women consuming the most anti-inflammatory diets were 26% less likely to develop depression than the women consuming the most pro-inflammatory diets.

The second study (Chang et al, American Journal of Clinical Nutrition, doi: 10.3945/ajcn.115.124545, 2016) was designed to test the association between flavonoid intake and depression in middle aged and older American women. This study followed 82,643 women ages 36-80 for an average of 10 years.

Flavonoid intake was calculated based on food frequency questionnaires administered every 4 years. Depression was assessed based on several well established ratings systems.

Again, this was a very well designed study, and the results were quite impressive:

  • Women who consumed the largest amounts of flavonoids were 7-10% less likely to develop depression than women consuming the least flavonoids.
  • When the study was broken down into flavonoid-containing foods, citrus fruits appeared to be particularly beneficial. Women consuming >2 servings per week were 18% less likely to develop depression than women consuming <1 serving per week.
  • Tea also scored high in their analysis. Women consuming >4 cups per day were 12% less likely to develop depression than women who rarely or never consumed tea.
  • While those flavonoid-rich foods stood out, the authors emphasized that there were no “magic” foods. It was a composite of all flavonoid containing foods that was related to lower depression risk.
  • The effect of a flavonoid-rich diet was particularly beneficial for older women. For women aged 65 or older at the beginning of the study, high flavonoid intake was associated with a 17% lower risk of developing depression.

 

Diets to Fight Depression:  The Secret

diets to fight depression secretsI have just described two very well designed studies on diets to fight depression in women. One concluded that an anti-inflammatory diet reduced the risk of depression while the other concluded that diets rich in flavonoids decreased the risk of depression. I have previously described studies suggesting that omega-3 fatty acids decrease depression risk in women and that consuming junk food increases depression risk . Other studies have suggested that a Mediterranean diet may significantly reduce depression.

If you are looking for a natural solution to recurring depression, these individual reports are probably confusing and overwhelming. I call it the “study du jour” syndrome. It can lead to paralysis. You just don’t know what you should try first.

What if these individual studies were like the blind men trying to describe an elephant?  Perhaps we need to step back and see if we can find the commonality in all of these studies. We need to look for the elephant.

For example, we might start by asking what is an anti-inflammatory diet? It turns out that diets rich in fruits, vegetables, fatty fish, olive oil and legumes are anti-inflammatory, while diets rich in saturated fats, cholesterol, and refined carbohydrates are pro-inflammatory. In short, the anti-inflammatory diet is very similar to the Mediterranean diet, and fully consistent with the reported benefits of omega-3 fatty acids. The pro-inflammatory diet, on the other hand, perfectly describes a junk food diet loaded with fat, cholesterol, and simple sugars and are not diets to fight depression.

What about diets rich in flavonoids? What are those flavonoid-rich foods? It turns out that flavonoids are found primarily in plant foods, and fruits, vegetables, and whole grains.  Beverages such as tea and coffee are particularly good sources.

So the secret is that there is no secret. Your mom was right all along. Eat your fruits, vegetables and whole grains. Take your fish oil. Take a vitamin supplement to make sure you didn’t miss anything. Avoid the junk foods. You’ll be healthier, and you’ll be happier. Include these in your diets to fight depression.

What Do These Studies Mean For You?

When considered individually these studies may seem confusing. However, when you consider them altogether the evidence is overwhelming. A good diet can significantly reduce your risk of depression, and a bad diet can make your depression even worse.

Of course, diet alone will not be enough to prevent depression in everyone. A more holistic approach would be to include exercise, socialization, and some stress reduction practices. Whether stress reduction occurs through yoga, meditation, counseling or other practices will vary from individual to individual.

Of course, if your depression is severe, professional help may be needed. I regard anti-depressant medications as a very last resort, but they can be life savers for some people.

So, with the inclusion of the right foods, the above studies seem to show there are diets to fight depression in women.

 

The Bottom Line

 

  • Two very good studies have recently been published concerning diet and depression in women:
  • One study concluded that an anti-inflammatory diet reduced the risk of depression in women.
  • Another study concluded that a diet rich in flavonoids reduced the risk of depression in women.
  • Other recent studies have concluded that diets rich in omega-3s and Mediterranean diets decrease depression risk in women. Another study concluded that consuming junk foods significantly increased depression risk.
  • When considered individually these studies may seem confusing. However, when you consider them altogether the evidence is overwhelming. A good diet can significantly reduce your risk of depression, and a bad diet can make your depression even worse.
  • Your mom was right all along. Eat your fruits, vegetables and whole grains. Take your fish oil. Take a vitamin supplement to make sure you didn’t miss anything. Avoid the junk foods. You’ll be healthier, and you’ll be happier
  • Of course, diet alone will not be enough to prevent depression in everyone. A more holistic approach would be to include exercise, socialization, and some stress reduction practices. If your depression is severe, professional help may be needed. I regard anti-depressant medications as a very last resort, but they can be life savers for some people.

 

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.

Skin Damage From Sun

Written by Dr. Steve Chaney on . Posted in Health Current Events, Skin Damage From Sun, Vitamin D

Author: Dr. Stephen Chaney

skin damage from sunSkin damage from sun is a real danger.  The dog days of summer are here. For some of us that means staying inside as much as possible. Others want to enjoy the fleeting days of summer as much as possible before summer turns to fall, and fall turns to winter. That means lots of outdoor activities in the sun – such as outdoor sports, working in the yard, and vacations in fun locations with lots of sun. So it’s time to ask the perennial question “How much sun exposure should I be getting?”

Some people like to aim for as much sun exposure as possible. When I was a teenager everybody was searching for “the perfect tan”. Back then it was popular to slather your skin with tanning oils that allowed you to just baste yourself in the sun without your skin drying up. (Did I just date myself again?)

Other people like to follow their dermatologist’s advice and use SPF maximum (the sun shall never touch my skin) sunscreens. And, just to be on the safe side they also follow their dermatologist’s advice to limit sun exposure between 10 AM and 4 PM and wear a hat, sunglasses, and protective clothing whenever possible. I can see the hat and sunglasses, but the protective clothing isn’t particularly compatible with the summer heat in my native North Carolina. Believe me, you want to wear as little as possible here in the summer.

Skin Damage From Sun

sun exposureNow that we’ve explored the extremes, let’s return to the central theme of this health tip which is “How much sun exposure should I really be getting?” Let’s start by focusing on the vanity factor – skin aging. Let’s face it. Excessive sun exposure increases the risk of skin cancer. However, skin aging is the consequence most people really care about. This is the concern that has most people reaching for the sunscreen before they head out the door.

A recent clinical study clearly showed that sunscreen usage helps prevent skin aging (Hughes et al, Annals of Internal Medicine, 158: 781-790, 2013). Now you might be saying to yourself “This is nothing new. I’ve heard that for years.” Yes, that advice has been around for a long time. But the problem is that the old advice was never based on actual clinical studies, only studies done on hairless mice. So first, let me analyze this clinical study for you and then put the findings into perspective.

The good news is that this was a very well done clinical study. The authors enrolled 903 adults under the age of 55 from sunny Australia into the study for a 4.5-year period from 1992 to 1996. The study was restricted to adults younger than 55 years because, in that age range, skin aging is primarily caused by sun exposure rather than the normal aging process. The study also excluded people who were already using sunscreen on a daily basis. Variables such as skin color, skin reaction to sun exposure, amount of time spent outdoors, sunburn history, and smoking status were determined at baseline and used to normalize the results.

Half of the participants were given a sunscreen with an SPF 15 factor and were instructed to use this sunscreen on a daily basis. The other half were given nothing and were just instructed to keep doing what they had been doing (It was deemed unethical to give them a placebo sunscreen as it could cause skin damage from sun). Compliance was assessed by measuring the weight of the returned sunscreen bottles every three months and by using a biennial application frequency questionnaire. Compliance wasn’t perfect, but of those enrolled in the sunscreen portion of the study 77% used sunscreen 3 to 4 times per week, compared to 33% of the control group.

Skin damage from sun was assessed by taking an impression of the back of the left-hand and analyzing it for the number and depth of lines and the flattening of the skin. And the results were fairly clear-cut. Those study participants who used sunscreen on a daily basis had 24% less sun damage over the 4.5-year period than the control group. I am not an expert, but dermatologists who have evaluated this study say that a 24% decrease in sun damage is visibly significant.

What Does This Study Mean For You?

It turns out that the old advice that too much sun exposure can cause significant skin damage as we get older is actually true. Who would have guessed? If the threat of skin cancer isn’t enough to dissuade you from pursuing the perfect tan, perhaps the thought of ugly, wrinkled skin as you get older will do it.

On the flip side, however, we need to remember that sun exposure is also required for vitamin D formation. And recent studies show that up to 80% of Americans have low levels of 25-hydroxy vitamin D, the biologically relevant form of vitamin D, in their blood – perhaps because many of us actually follow our dermatologist’s advice and never go out of the house without sunscreen, sunglasses, hat, and protective clothing to help prevent skin damage from sun.

Recent clinical studies have linked low levels of 25-hydroxy vitamin D with a number of health concerns. That has led one prominent dermatologist who studies vitamin D, Dr. Michael Holick, to recommend that we should be getting 10 to 15 minutes of unprotected sun exposure during midday – a recommendation that many of his colleagues consider to be heretical.

How Can You Have Your Cake And Eat It Too?

vitamin DSo what is a person to do? How can we reconcile the need to improve our vitamin D status with our desire to have a healthy, good looking skin well into our golden years? The simple answer is to make sure that we are getting plenty of vitamin D in our diet. The most recent RDAs are 600 IU per day of vitamin D in children and adults up to the age of 70 and 800 IU per day for adults over 70.

Many experts are even recommending that we get 1000 to 2000 IU of vitamin D per day. The Institute of Medicine (the group that actually sets the RDAs) considers that to be in the safe range for vitamin D intake. If you are thinking of exceeding that dosage, my advice would be to first get your 25-hydroxy vitamin D levels determined (20-50 ng/ml or 50-125 nmol/L is considered optimal) and then consult with your doctor as to what the best dosage of vitamin D is for you.

And, if you are relying on supplements for your vitamin D intake, you should be sure to choose a company that manufactures their supplements according to pharmaceutical standards. A recent study(E. S. LeBlanc et al, JAMA Internal Medicine, 173:585-586, 2013)  analyzed commercially available vitamin D supplements and found some brands in which the potency from bottle to bottle ranged from 9% to 140% of what was on the label. That is unacceptable.

 

The Bottom Line

  • A recent study has confirmed what we have been told for years, namely that regular use of an SPF 15 sunscreen reduces skin aging. Specifically, the study showed that regular sunscreen use reduced skin aging by 24% over a 4.5-year period in people 55 years old or younger.
  • On the other hand, sun exposure is required for our bodies to synthesize the active form of vitamin D. Vitamin D experts like Dr. Michael Holick recommend that we get at least 10-15 minutes of unprotected sun exposure a day during the summer months to assure that our bodies make the vitamin D we need for optimal health.
  • If you want both young looking skin and optimal vitamin D status, you will probably want to consider a vitamin D supplement. Recommendations for how much and what kind of vitamin D supplement are found in 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.

American Omega-3 Deficiency

Written by Dr. Steve Chaney on . Posted in Food and Health, Health Current Events, Omega-3 Deficiency, Supplements and Health

Is There an American Omega-3 Deficiency?

Author: Dr. Stephen Chaney

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

Omega-3 Deficiency in Americans

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

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

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

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

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

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

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

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

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

What Does This Study Mean To You?

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

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

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

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

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

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

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

Where Should You Get Your Omega-3s?

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

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

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

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

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

 

The Bottom Line

 

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

 

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

Omega-3 And Blood Pressure: The Good News

Written by Dr. Steve Chaney on . Posted in current health articles, Diets, Food and Health, Health Current Events, Omega-3s and Blood Pressure, Supplements and Health, Vitamins and Health

Will Fish Oil Lower Your Blood Pressure?

Author: Dr. Stephen Chaney

 

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

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

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

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

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

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

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

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

 

The Good News About Omega-3 and Blood Pressure

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

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

Here are the results of this study:

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

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

Here are the results of this study:

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

A Holistic Approach To Blood Pressure Control

 

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

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

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

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

 

A Word Of Caution

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

My recommendations are:

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

 

The Bottom Line

 

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

 

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

PAHs Contaminate Supplements?

Written by Dr. Steve Chaney on . Posted in current health articles, Environment and Health, Food and Health, Health Current Events, Supplements and Health

Do Your Supplements Contain Carcinogens?

Author: Dr. Stephen Chaney

 

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

Where Do PAHs Come From  andWhy Are TheyDeadly?

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

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

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

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

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

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

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

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

Do Your Supplements Contain PAHs or Other Carcinogens?

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

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

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

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

The results of their analysis were pretty scary:

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

Why The PAH and Contamination Problem Is Worse Than You Thought

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

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

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

 

The Bottom Line

 

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

 

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

Do B Vitamins Reduce Heart Disease Risk?

Written by Dr. Steve Chaney on . Posted in current health articles, Drugs and Health, Health Current Events, Healthy Lifestyle, Supplements and Health, Vitamins and Health

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

Author: Dr. Stephen Chaney

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

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

Do B Vitamins Reduce Heart Disease Risk?

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

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

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

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

The Flaws In The Study

flawsThere were two major flaws in this study.

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

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

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

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

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

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

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

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

What Does This Study Mean For You?

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

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

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

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

 

The Bottom Line

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

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

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

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

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

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

 

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

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

Written by Dr. Steve Chaney on . Posted in current health articles, Drugs and Health, Exercise, Food and Health, Health Current Events, Healthy Lifestyle, Supplements and Health

Creating A “Bone Healthy” Lifestyle

Author: Dr. Stephen Chaney

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

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

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

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

What Is A “Bone Healthy” Lifestyle?

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

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

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

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

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

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

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

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

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

Exercise Is A Critical Part of  Preventing Osteoporosis

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

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

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

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

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

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

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

Putting It All Together –  A “Bone Healthy” Lifestyle

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

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

What About Medications For Preventing Bone Loss?

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

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

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

 

The Bottom Line

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

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

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

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

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

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

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

 

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

Do Calcium Supplements Prevent Bone Fractures? – Part1

Written by Dr. Steve Chaney on . Posted in current health articles, Health Current Events, Supplements and Health, Vitamins and Health

Why The Recent Headlines May Be Misleading

Author: Dr. Stephen Chaney

 

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

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

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

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

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

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

Bone Metabolism and Osteoporosis

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

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

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

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

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

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

Do Calcium Supplements Prevent Bone Fractures?

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

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

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

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

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

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

Garbage-In, Garbage-Out

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

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

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

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

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

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

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

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

Apples and Oranges

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

But what if they were comparing apples and oranges?

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

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

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

 

The Bottom Line

 

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

 

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

Should You Eat Often to Lose Weight?

Written by Dr. Steve Chaney on . Posted in current health articles, Health Current Events, Healthy Lifestyle, Lose Weight

6 Small Meals a Day Plan?

Author: Dr. Stephen Chaney

eat like a birdShould you eat often to lose weight?  A friend, your doctor, or your favorite health guru may have told you with some conviction that eating 6 small meals a day, as opposed to 2 or 3 large meals, can help you lose weight. If you are like most people, you are probably wondering whether something so simple might be the secret to permanent weight control. Should you really eat like a bird?

The advocates of eating frequent, small meals argue that large meals cause a much larger spike in insulin resulting in more of the calories being stored as fat. They also argue that a long time between meals leads to excessive hunger and overeating when you do sit down to a meal. The opponents of this idea claim that those arguments are nonsense and that eating frequent meals can cause you to lose track of the calories you have consumed.

The clinical studies on this subject have not been much help. Some studies show that more frequent food consumption during the day is associated with lower body weight, while other studies find no association between frequency of food consumption and weight.

Your friend may have also told you that consuming your calories earlier in the day will help prevent weight gain. You’ve probably heard the saying: “Eat breakfast like a king, lunch like a prince, and dinner like a pauper”. This hypothesis is on a bit stronger footing, but there are far too few studies on the subject.

With both of those concepts in mind, a recent study provides an excellent perspective.

Should You Eat Often to Lose Weight?

A recent study (Aljuiraban et al., Journal of the Academy of Nutrition and Dietetics, 115: 528-536, 2015) used data from the International Study on Macro/Micronutrients and Blood Pressure to evaluate the relationship between frequency of eating and time of eating with caloric density (calories/serving), nutrient quality and BMI (a measure of body weight). The study included 2,696 men and women aged 40 to 59 years from both the United States and England. The dietary data were obtained from each participants on two consecutive days at the beginning of the study and again 3 weeks later.

The results of the study were:

  • BMI was significantly less for those individuals consuming >6 meals per day than for those consuming <4 meals/day.
  • BMI was also significantly less for those individuals consuming their calories early in the day than for those consuming most of their calories late in the day.

What Is The “Rest Of The Story”?

Those of you old enough to have heard the Paul Harvey radio show might remember that he would tell a fairly ordinary story. Then, after the commercial break, he would come back and tell “The Rest Of The Story”, and that was always the most interesting part of the story. This study is no different.

should you eat often to lose weightIf this study had just measured associations with BMI, it would have been just another boring food frequency study that just happened to show an association between more frequent food consumption and lower body weight. However, it also evaluated the association of food frequency and food timing with many other parameters. This was the most interesting part of the study. This was “the rest of the story”.

  • Those individuals consuming >6 meals/day had higher intakes of low fat dairy products, fruits and vegetables and lower intake of alcohol and red meats than those consuming <4 meals/day.
  • Those individuals consuming >6 meals/day also consumed less energy dense foods, fewer total calories, and more nutrient rich foods than those individuals consuming <4 meals/day.
  • Those individuals consuming >6 meals per day were much less likely to have their evening meal at a restaurant or cafeteria than those individuals consuming <4 meals/day.
  • Similarly, those individuals consuming the majority of their calories early in the day also had higher intake of low fat dairy products, fruits and vegetables and lower intake of alcohol and red meat than those consuming the majority of their calories late in the day. They also consumed less energy dense foods, fewer total calories, and more nutrient rich foods.
  • Although the difference was not statistically significant, it is perhaps worth noting that individuals consuming >6 meals/day tended to eat a higher percentage of their calories early in the day compared to individuals consuming <4 meals/day.

In other words, it was not necessarily the frequency or time of eating that was associated with body weight. It could simply have been the quality of the diet that determined body weight. It’s no secret that eating fewer calories, more fresh fruits and vegetable, eating lower fat dairy products, and consuming less alcohol and red meat is associated with a lower body weight. In today’s world of supersized portions, it’s also not surprising that frequently eating your dinner at restaurants is associated with higher weight.

What’s not clear from this study is why there was such a strong association between consuming a healthy, low calorie diet and frequency/timing of eating. It’s also not clear whether this is a universal association, or whether it was unique to this clinical study.

 

The Bottom Line

  • A recent study has shown that BMI was significantly less for those individuals consuming >6 meals per day than for those consuming <4 meals/day. BMI was also significantly less for those individuals consuming the bulk of their calories early in the day compared to those consuming their calories late in the day.
  • In both cases, it turns out that the individuals with lower BMI were also consuming healthier diets as measured by lower calorie intake, greater consumption of fruits, vegetables and low fat dairy and reduced consumption of alcohol and red meats.
  • Consequently, it isn’t clear from this study whether low BMI is associated with frequency of eating, timing of eating, or simply the quality of the diet.
  • The jury is still out on whether consuming frequent, small meals can help you lose weight. This just may be one of those approaches that works better for some people than for others.
  • The preponderance of evidence suggests that consuming the bulk of your calories early in the day may help you lose weight, but the evidence is far from definitive at this point.
  • However, there is universal agreement that eating a healthy, low calorie diet will help you lose weight. My money is with a healthy, low calorie diet.

 

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.

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The Truth About Vitamin D

Posted December 11, 2018 by Dr. Steve Chaney

Does Vitamin D Reduce Risk Of Heart Disease & Cancer?

Author: Dr. Stephen Chaney

 

the truth about vitamin dYou have every right to be confused. One day you are told that vitamin D reduces your risk of heart disease and cancer. The next day you are told vitamin D makes has no effect on those diseases. You are told vitamin D is a waste of money. What should you believe?  What is the truth about vitamin D?

In mid-November a major clinical study called VITAL was published. It examined the effect of vitamin D and omega-3s on heart disease and cancer risk. Last week I wrote about the omega-3 portion of the study. This week I will cover the vitamin D portion of the study.

Once again, if you rely on the media for your information on supplementation, you are probably confused. Headlines ranged from “Vitamin D Is Ineffective For Preventing Cancer And Heart Disease to “Vitamin D Lowers Odds Of Cancer Death.” What is the truth?

The problem is that reporters aren’t scientists. They don’t know how to interpret clinical studies. What they report is filtered through their personal biases. That is why I take the time to carefully evaluate the clinical studies, so I can provide you with accurate information. Let me sort through the dueling headlines and give you the truth about vitamin D, cancer, and heart disease.

How Was The Study Designed?

the truth about vitamin d studyThe 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. The characteristics of the study group were typical of the American population at that age, namely:

  • The average BMI was 28, which means that most of the participants were significantly overweight.
  • 7% of them had diabetes.

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. The participants were given either 2,000 IU of vitamin D/day or a placebo and followed for an average of 5.3 years.

There were two important characteristics of the participants in this study that may have influenced the outcome.

  • 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 the optimal level of 25-hydroxyvitamin D for most physiological functions. This means that study participants started in the middle of the optimal range with respect to vitamin D status.

[Note: The NIH defines the 20-50 ng/ml range as “adequate.”  However, I know many of my readers like to aim beyond adequate to reach what they consider to be “optimal.”  In the case of vitamin D, that might not be a good idea. The NIH considers anything above 50 ng/ml as associated “with potentially adverse effects.”  For that reason, I will refer to the 20-50 ng/ml range as optimal for this article. I wouldn’t want to encourage my readers to be aiming for above 50 ng/ml.]

  • Only 12.7% of participants had 25-hydroxyvitamin D levels below 20 ng/ml, which the NIH considers to be inadequate. The results with this group were not statistically different from the study participants with optimal vitamin D status, but it is not clear that there were enough people in this subgroup for a statistically valid comparison with participants starting with an optimal vitamin D status.
  • At the end of the first year, 25-hydroxyvitamin D levels in the treatment group increased to 42 ng/ml (105 nmol/L), which is near the upper end of the optimal range. Thus, for most of the participants, the study was evaluating whether there was a benefit of increasing vitamin D status from the middle to the upper end of the optimal range.
  • The study allowed subjects to continue taking supplements that contained up to 800 IU of vitamin D. While the authors tried to correct for this statistically, it is a confounding variable.

Does Vitamin D Reduce The Risk Of Cancer?

 

the truth about vitamin d and cancerYou may remember from last week that omega-3s were more effective for reducing heart disease risk than for reducing cancer risk. What is the truth about vitamin D and cancer risk?   The results are reversed for vitamin D, so I will discuss cancer first.

The study reported that vitamin D supplementation did not reduce a diagnosis of invasive cancer of any type, breast cancer, prostate cancer, or colon cancer during the 5.3-year time-period of this study. This was the result that was reported in the abstract and was what lazy journalists, who never read past the abstract, reported.

However, the rest of the study was more positive. For example, occurrence of invasive cancer of any type was reduced by:

  • 23% in African-Americans.
  • 24% in patients with a healthy body weight.

Several previous studies have suggested that vitamin D may be more effective at preventing cancer in people with a healthy body weight, but the mechanism of this effect is currently unknown.

Most previous studies have not included enough African-Americans to determine whether they respond more favorably to vitamin D supplementation. However, African-Americans have a higher risk of cancer, so this finding deserves follow-up.

In addition, when the study looked at deaths from cancer, the results were very positive. For example:

  • Cancer deaths during the 5.3-year study period were reduced by 17%.
  • The longer vitamin D supplementation was continued the more effective it became at reducing cancer deaths. For example,
  • When the authors excluded cancer deaths occurring during the first year of supplementation, vitamin D reduced cancer deaths by 21%.
  • When the authors excluded cancer deaths occurring during the first two years of supplementation, vitamin D reduced cancer deaths by 25%.

Finally, no side effects were noted in the vitamin D group.

 

Does Vitamin D Reduce The Risk Of Heart Disease?

 

the truth about vitamin d and heart diseaseThe VITAL study also looked at the effect of vitamin D on heart disease risk. What is the truth about vitamin D and heart disease?  The results from this study were uniformly negative. There was no effect of vitamin D supplementation on all major cardiovascular events combined, heart attack, stroke, or death from heart disease. Does that mean vitamin D has no role in reducing heart disease risk? That’s not clear.

The authors had a thought-provoking explanation for why the results were negative for heart disease, but positive for cancer. Remember that the participants in this trial started with a 25-hydroxyvitamin D level of 31 ng/ml and increased it to at least 42 ng/ml with vitamin D supplementation.

The authors stated that previous studies have suggested the 25-hydroxyvitamin D level associated with the lowest risk for heart disease is between 20 and 25 ng/ml. If that is true, most of the participants in this trial were already in the lowest possible risk for heart disease with respect to vitamin D status before the study even started. There would be no reason to expect additional vitamin D to further reduce their risk of heart disease.

In contrast, the authors said that previous studies suggest the 25-hydroxyvitamin D level associated with the lowest risk of cancer deaths is above 30 ng/ml. If that is true, it would explain why vitamin D supplementation in this study was effective at reducing cancer deaths.

However, previous placebo-controlled clinical studies have also been inconclusive with respect to vitamin D and heart disease. My recommendation would be to think of adequate vitamin D status as part of a holistic approach to reducing heart disease – one that includes a heart-healthy diet and a heart-healthy lifestyle – rather than a “magic bullet” that decreases heart disease risk by itself.

As for heart-healthy diets, I discuss the pros and cons of various diets in my book, “Slaying The Food Myths.”  As I discuss in my book, the weight of scientific evidence supports primarily plant-based diets that include omega-3s as heart healthy. As an example, the Mediterranean diet is primarily plant-based and is rich in healthy oils like olive oil and omega-3s. It is associated with reduced risk of both heart disease and cancer.

 

What Is The Truth About Vitamin D?

 

the truth about vitamin d signThere is a lot of confusion around the question of whether vitamin D reduces the risk of cancer. This study strengthened previous observation suggesting that vitamin D supplementation decreases cancer deaths. However, it is also consistent with previous studies that have failed to find an effect of vitamin D on cancer development. How can we understand this apparent discrepancy? The authors provided a logical explanation. They pointed out that:

  • Cancer development takes 20-30 years while this clinical study lasted only 5.3 years. That means that vitamin D supplementation only occurred at the tail end of the cancer development process. In fact, the cancer was already there in most of the patients in the study who developed cancer. It just had not been diagnosed yet. In the words of the authors: “Given the long latency for cancer development, extended follow-up is necessary to fully ascertain potential effects [of vitamin D supplementation].”
  • In contrast, none of the patients had been diagnosed with cancer when they entered the trial. That means that the patients were diagnosed with cancer during the 5.3-year study period. They were receiving extra vitamin D during the entire period of cancer treatment. Thus, the effect of vitamin D on reducing cancer deaths was easier to detect.

What Does This Study Mean For You?

the truth about vitamin d questionsVitamin D Is Likely To Decrease Your Risk Of Dying From Cancer: When you combine the results of this study with what we already know about vitamin D and cancer, the results are clear. Vitamin D appears to reduce your risk of dying from cancer. More importantly, the longer you have been supplementing with vitamin D, the greater your risk reduction is likely to be.

Vitamin D May Decrease Your Risk Of Developing Cancer: Association studies suggest that optimal vitamin D status is associated with decreased cancer risk, especially colon cancer risk. However, the long time for cancer development means that we may never be able to prove this effect through double-blind, placebo-controlled clinical trials.

Holistic Is Best: When you combine the VITAL study results with what we already know about vitamin D and heart disease, it appears that supplementing with vitamin D is unlikely to reduce your risk of developing heart disease unless you are vitamin D deficient. However, a holistic approach that starts with a healthy, primarily plant-based diet and makes sure your vitamin D status is adequate is likely to be effective.

The same is likely true for cancer. While the latest study suggests that vitamin D supplementation reduces your risk of dying from cancer, those vitamin D supplements are likely to be even more effective if you also adopt a healthy diet and lifestyle.

How Much Vitamin D Do You Need? The optimal dose of vitamin D is likely to be different for each of us. One of the things we have learned in recent years is that there are significant differences in the efficiency with which we convert vitamin D from diet and/or sun exposure into the active form of vitamin D in our cells. Fortunately, the blood test for 25-hydroxyvitamin D is readily available and is widely considered to be an excellent measure of our vitamin D status.

I recommend that you have your blood level of 25-hydroxyvitamin D tested on an annual basis. Based on the best currently available data, I recommend you aim for >20 ng/ml (50 nmol/L) if you wish to minimize your risk of heart disease and >30 ng/ml (75 nmol/L) if you wish to minimize your risk of cancer. If you can achieve those levels through diet and a multivitamin supplement, that is great. If not, I would recommend adding a vitamin D supplement until those levels are achieved.

Finally, you shouldn’t think of vitamin D as a magic bullet. If you are a couch potato and eat sodas and junk food, don’t expect vitamin D to protect you from cancer and heart disease. You should think of maintaining adequate 25-hydroxyvitamin D levels as just one component of a holistic approach to healthy, disease-free living.

 

The Bottom Line

 

There is a lot of confusion around the question of whether vitamin D reduces the risk of cancer and heart disease. A major clinical study has just been published that sheds light on these important questions. It reported:

  • Vitamin D did not decrease the risk of developing cancer during the 5.3-year study duration. The authors pointed out that cancer takes 20-30 years to develop, which means their study was probably too short to detect an effect of vitamin D on the risk of developing cancer.
  • Vitamin D did decrease the risk of dying from cancer, and the longer people were supplementing with vitamin D the bigger the protective effect of vitamin D was.
  • Vitamin D did not decrease the risk of heart disease. However, most study participants had a level of 25-hydroxyvitamin D that was optimal for reducing the risk of heart disease at the beginning of the study. There was no reason to expect that extra vitamin D would provide additional benefit.
  • With respect to both cancer and heart disease the best advice is to:
    • Get your 25-hydroxyvitamin D levels tested on an annual basis and supplement, if necessary, to keep your 25-hydroxyvitamin D levels in what the NIH considers to be an adequate range (20-50 ng/ml).
    • We do not have good dose response data for the beneficial effects of vitamin D on heart disease and cancer. However, according to this article, previous studies suggest you may want to am for 25-hydroxyvitamin D levels above 20 ng/ml to reduce the risk of heart disease and above 30 ng/ml to reduce your risk of cancer.
    • Consider vitamin D as just one component of a holistic approach to healthy, disease-free living.

For more details about the interpretation of these studies and what they mean 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.

 

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