Seattle Nutritionist, Angela Pifer, writes:
You may or may not have heard about the latest recommendations from the government advisory board, the Institute of Medicine’s (IOM) U.S. Preventive Services Task Force. News headlines over the past two days have read: women who are postmenopausal should not take vitamin D and calcium for bone health – these supplements do not prevent fractures. Did the IOM get this right?
The IOM states that, “Vitamin D and calcium supplements do not prevent fractures in adult men or women, according to a report published in the journal Annals of Internal Medicine.” Side note: statin drugs do not lower the risk of heart attack or frequency of heart attack and yet, I have heard no such recommendation to remove statin drugs. But yet, I do digress.
The topic of bone health is an important one for women and men. The often conflicting recommendations made regarding what to take and what not to take on the evening news, simply increase consumer confusion. To best manage your healthcare, find a health care practitioner that you feel is a partner in your health. The two of you will decide the right course of action.
I had the pleasure of attending a lecture by Dr. Michael McClung in Portland last year, speaking on bone health “Current Issues and Conventional Treatment Updates in Osteoporosis.” Dr. McClung is a member of the global advisory board on osteoporosis and bone health.
It was an interesting lecture. He spoke to a large group of naturopaths, nutritionist, etc (all grouped as ‘alternative practitioners’). It is always interesting comparing the approach of MD versus ND. I personally have a pet peeve regarding my certification being lumped under ‘alternative practitioner.’ If all practitioners addressed clinical nutrition needs, we would have far less need for medications.
Dr. McClung’s view point was an interesting one; made even more interesting after I heard of this latest recommendation from the advisory board. During his presentation he made the following points:
- The Institute of Medicine (IOM) states that 20ng/ mL Vitamin D levels are adequate in the body.
- Cautions about going over 30ng/ mL
- Most labs report ’20-30ng/ mL’ as standard adequate range
- Studies looking at vitamin D levels have not focused above 30ng/ mL. The max seen in the studies is 22ng/mL (*note this level, this is an important point in this discussion). The studies used 200-800IU (800IU max) vitamin D as a daily supplement level to bring levels to 20ng/mL and called this a ‘repleted’ level.
I asked Dr. McClung a question, ‘What level of vitamin D do we see in surfers and farm workers (those out in the sun constantly).’ His reply, ’50-80ng/ mL.’ So, why the shortfall? Why not consider 40-50 ng/mL as a more ideal range for vitamin D levels versus 20ng/mL? His reply to me, ‘We are talking about supplementing and not getting this from the sun.’ This last answer didn’t sit very well with me. If someone is iron deficient, we bring their iron levels back up with supplements. If B12 deficient, we offer shots or supplements to bring their levels back up. We are simply not in the sun as much as we once were. Sun screen is in makeup and is overused whenever the sun makes an appearance (however brief) and we are working more and more hours indoors. In the Northwest, there are 2.5 months during the year that we can absorb and convert vitamin D from the sun’s rays. These all reduce our chances of building adequate levels of vitamin D.
So, when you hear these new recommendations to stop taking calcium and vitamin D because they do not improve bone health or reduce factures, it has to be put into context. The doctors that made this recommendation are looking at 20ng/ mL of vitamin D – nowhere near the level of vitamin D that the body would naturally prefer to regulate itself at 50-80ng/mL (if offered adequate sun exposure).
“Everyone wants vitamin D to be the new magic bullet to prevent all kinds of chronic disease, but the evidence is inconsistent and inconclusive at this time to warrant levels beyond our recommendations,” says Harvard’s JoAnn Manson, PhD, MD, and member of the Institute of Medicine (IOM) vitamin D and calcium committee. Interesting side note: well-known Harvard physician Dr. Walter Willet, wrote a rebuttal to the IOM findings, stating that their calcium recommendations were too high (we’ll get to this in a minute) and the recommended vitamin D levels were too low.
Vitamin D levels with respect to mortality are mapped as a ‘J curve.’ If a person’s vitamin D levels are under 20ng/mL their risk for mortality goes up. If over 80mg/ mL their risk for mortality goes up. It simply does not make sense that we would assume that at 20ng/mL a person is repleted. This may be the very, very low range of repletion and yet not the optimal range, which is likely closer to 40-50ng/ mL.
If you remember back in 2010, this same advisory group recommended an increase in the daily vitamin D dose from 200IU to 400IU. Again, in context, this makes sense. The majority of studies done in this area are looking at 200-800IU of vitamin D and 20ng/mL as a repleted level. Why are they doing this? Dr. McClung said that they came to this conclusion, that 20ng/mL was a repleted level, because, “this is the current average vitamin D levels for Americans.”
So, if we are all depleted, this is the new standard that we compare to? How scientific is that?
The new IOM recommendations for vitamin D:
- Ages 1-70: 600 international units (IUs) per day. Older than 71: 800 IUs. The IOM previously said 200 IUs was adequate for people aged 50 and younger, 400 IU for people aged 51-70, and 600 IUs for people older than 70.
- The tolerable upper limit (UL) is 4000 IUs for ages 9 and above (up from 2000 IU in the IOM’s previous guidance).
To note, the IOM committee has made this recommendation to postmenopausal healthy women with respect to bone health and fracture risk. One glaring issue here is the huge body of evidence that shows the important role of vitamin D in the body beyond its role in whether it prevents facture risk (at 20ng/mL vitamin D). The body makes vitamin D when exposed to sunlight. But the IOM committee didn’t factor that into the recommendations, because many factors (including, skin color, and geographic location) affect that process. Nor did the committee make any recommendations regarding supplements. To put this all into perspective, your body can produce 10,000IU units of vitamin D per hour from unobstructed sun exposure.
There has been evidence that higher vitamin D levels increase bone density. In the very large population-based NHANES analysis, bone density increased with higher vitamin D levels far beyond 50 nmol/l (20 ng/ml) in younger and older adults. This is further evidence that the IOM threshold recommendation is too low for optimal bone health in adults.
The IOM’s findings are controversial among many medical doctors. In his book, The Vitamin D Solution, Michael Holick, PhD, MD, author and vitamin D researcher, recommends an upper limit of 10,000 IUs for adults and 5,000 IUs for children. Robert Heaney, MD, a vitamin D researcher and Creighton University professor, agrees with the IOM for raising the upper limit of vitamin D from 2,000 to 4,000IU but would like to see it even higher, stated, “I am delighted the upper limit for vitamin D has been doubled to 4000 IUs per day, although this is a conservative level, considering the body of scientific evidence indicating it should be 10,000 IUs,” Heaney says. “However, few people need more than 4000 IUs, which will meet the needs of most healthy people, give physicians confidence to recommend supplementation, and allow research at higher vitamin D levels.” This last point is important. Just like vitamin E in the alpha-tocopherol from is the form most often used in studies (based on guidelines laid down by government advisory boards) so too are the levels of vitamins used in studies. Meaning that, the bulk of studies will not look beyond using 2,000IU of vitamin D if the IOM states that the upper limit of vitamin D per day is 2,000IU. Now that it has been raised to 4,000IU, larger doses of vitamin D will be used in studies.
Let’s talk calcium…
The new recommendations of the IOM call for a calcium:
- 700 milligrams (from all sources, mainly food) for children ages 1 to 3 up to 1,200 milligrams for women 51 and older.
- Compared to the last IOM report, calcium recommendations remained largely the same with a small reduction for men age 50 to 70 to 1,000 from 1,200 milligrams per day. The panel confirms a safe upper limit of 2,000 to 3,000 milligrams of calcium per day for adults.
This is in contrast to what you heard on the news. The headline that I led with in this article is the same headline that all the major news casts led with: “Women who are postmenopausal and looking to improve bone health should not take vitamin D and calcium – these supplements do not prevent fractures”
At the conference in Oregon, Dr. McClung made these following points about calcium:
- If vitamin D deficient and taking calcium supplements, there is an increased risk of side effects (heart attack among them)
- The max calcium intake per day should be around 1200mg/ day (including food)
- If a person is dairy free, assume they are getting 300 mg/ day calcium from their current food sources
- So, The max calcium intake from supplements per day should be 500-600mg
I do agree with Dr. McClung’s recommendations for calcium supplementation. I feel that the IOM’s recommendations are too high. We do get some calcium from food. Instead of looking at large single nutrient supplementation, we need to first consider food sources (what the person is getting from food), second consider focusing on food sources (so they can increase their intake of the nutrient from natural sources) and third, consider the blend of nutrients that will best support health. Nutrients are rarely consumed in large single doses. There are 19 key nutrients in bone building – calcium is just one among them.
For example, the type of vitamin E in most supplements is ‘alpha-tocopherol.’ There are many forms of vitamin E. Alpha-tocopherol, beta-tocopherol, delta-tocopherol and gamma-tocopherol are among them. When vitamin studies are done, vitamin E in its alpha-tocopherol form is used. When alpha-tocopherol is given in large doses, one effect is that gamma-tocopherol levels decrease in the body. Gamma-tocopherol inhibits platelet aggregation (when platelets form in an artery, plaque buildup occurs). So, studies based on vitamin E (alpha- tocopherol form) are shown to increase instances of plaque buildup in the arteries, which increases heart attack rise. The conclusion is: ‘Vitamin E increases plaque buildup and risk for heart attack.’ When, in reality the study design that was flawed. Vitamin E should rarely be taken in one form. When taking a vitamin E supplement, the best choice is to take a ‘mixed tocopherol vitamin E;’ one that contains all forms of vitamin E.
This same point holds true for the flawed nature of supplement studies; those on calcium included. Based on flawed analysis, one meta-analysis concluded that calcium supplements increase heart attack risk by 27%. Excluded from these studies were people who took vitamin D, magnesium or other nutrients typically found in bone protection formulas. In other words, calcium-supplemented study subjects (who the analysis claims suffered higher heart attack rates) may have been deficient in vitamin D and magnesium — two essential nutrients that protect against heart attack.
The doctors who compiled this analysis also dismissed two major clinical trials showing that those with higher calcium intake had significantly lower cardiovascular rates (NHANES analysis referenced earlier in this article). I do want to emphasize, however, the need to supplement with other nutrients when taking calcium for optimal effect.
As we age, the body’s internal regulators of calcium deposition become less efficient. New studies have uncovered a deficiency of vitamin K as being a factor that enables calcium to infiltrate the inner lining of arteries to cause arterial calcification. Consider the person on a typical American diet who is taking large doses of calcium, say 1500mg/ day and who is not getting in adequate magnesium (nuts and seeds), vitamin D (lack of sun) and vitamin K (dark leafy greens). This person may be at higher risk for arterial calcification AND be at greater risk for osteoporosis because there are 19 synergistic nutrients that work to support bone health in the body (most of which are not going to be provided in a typical American diet).
By ensuring optimal vitamin K status, calcium is directed to the bone and away from the arterial wall. With new studies showing the effectiveness of K2, vitamin K (in the form of K2) should be added to a therapeutic regimen. In a previous FORUM posting on osteoporosis, you may have noticed that I recommended a supplement protocol that included K2 (vitamin K), calcium/ mg in a 2:1 ratio (600 mg calcium: 300mg magnesium), and 2000IU vitamin D3.
Magnesium is a critical nutrient for bone and cardiovascular health. Of interest, magnesium is considered a natural calcium-channel blocker that supports endothelium-dependent relaxation of blood vessels. For optimal bone AND cardiovascular health, a combination calcium, magnesium, K2 and vitamin D offers a balanced support.
Optimal bone health and protection against atherosclerosis requires a multifactorial approach that involves far more than taking only calcium in large doses. The recently published meta-analysis, does offer one valuable lesson – large doses of single nutrients (vitamins OR minerals) do not often evoke the desired response and may even be harmful.
Angela Pifer, Certified Nutritionist with Nutrition Northwest. Seattle Nutritionist