Are Calcium Supplements Heart Healthy?

February 6, 2024 by Dr. Steve Chaney

Should You Follow Your Doctor’s Advice About Calcium Supplementation?

Author: Dr. Stephen Chaney

Are calcium supplements good for your heart or bad for your heart? If you don’t know the answer to that question, don’t feel badly. You have every right to be confused. Some studies say that calcium supplements increase heart disease risk while others say they decrease heart disease risk. The headlines have veered between “killer calcium” and “beneficial calcium”.

The trend appears to be moving in a positive direction. In recent years most of the studies have suggested that calcium supplements either decrease heart disease risk or have no effect on heart disease risk.

However, the medical profession has been slow to take note of this trend. Most medical societies and health professionals have focused on earlier studies and are still recommending that their patients get calcium from food rather than from supplements. I will talk more about that recommendation below.

With this context in mind, this week I will review and discuss the results from the latest study (MG Sim et al, Heart, Lung and Circulation, 32: 1230-1239, 2023) on the effect of calcium supplementation on heart disease risk.

How Was This Study Done?

The authors of this study performed a meta-analysis of 12 double-blinded randomized clinical trials with 87,899 participants comparing the effect of a calcium supplement versus a placebo on heart disease outcomes (heart attack, stroke, heart failure, cardiovascular mortality, and all-cause mortality).

The studies included in this analysis:

Used calcium doses from 500 mg/day to 2,000 mg/day.

Used supplements with calcium coming from a variety of sources (calcium carbonate, calcium citrate, calcium gluconolactate, and tricalcium phosphate).

Ranged from 18 months to almost 12 years in length.

Were performed with population groups from a wide range of countries (United States, England, France, Australia, New Zealand, European Union, Denmark, and Thailand).

Included calcium supplements with and without vitamin D.

Were primarily (86% of participants) conducted with post-menopausal women. One small study (0.3% of participants) was conducted with non-osteoporotic men. The rest were conducted with mixed populations (men and women) diagnosed with colorectal adenoma.

Are Calcium Supplements Heart Healthy?

This is the largest meta-analysis performed to date of double-blind, placebo-controlled randomized clinical trials on the effect of calcium supplementation versus a placebo on heart disease outcomes. This study found no effect of calcium supplementation on:

Heart attack.
Stroke
Heart failure.
Cardiovascular mortality.
All-cause mortality.

This study also evaluated potential confounding variables and found no effect of calcium supplementation on heart disease risk for:

Calcium supplements with and without vitamin D.

Dosage of calcium in the supplements (The dosage ranged from 500 mg/day to 2,000 mg/day).

Females (I suspect the number of males in this study was too small to come to a statistically significant conclusion).

Duration of calcium supplementation ≤ 5 years (The shortest duration of calcium supplementation in these studies was 18 months).

Different geographical regions.

However, this meta-analysis reported considerable variation between studies included in the analysis. Simply put,

Some studies showed an increase in heart disease risk.
Some studies showed a decrease in heart disease risk.
Some studies showed no effect on heart disease risk.

What this analysis showed was that when you combine all the studies, the aggregated data is consistent with calcium supplementation having no effect on heart disease risk.

The authors concluded, “Calcium supplementation was not associated with myocardial infraction [heart attack], stroke, heart failure, and cardiovascular/all-cause mortality. Further studies are required to examine and understand these associations.

Should You Follow Your Doctor’s Advice About Calcium Supplementation?

As I said above, most medical societies and health professionals have focused on earlier studies and are still recommending that their patients get calcium from food rather than from supplements. That may be the advice you are getting from your doctor.

Before you assume your doctor isn’t keeping up with the latest science and ignore his or her advice, we should ask why they are giving that advice. The top three reasons most medical societies give for recommending dietary sources of calcium are:

1) Some studies do show an increased risk of heart disease associated with calcium supplementation. The prime directive for health professionals is to do no harm. Yes, the average of all studies shows no effect of calcium supplementation on heart disease risk. But what if the studies showing increased risk are true for some of their patients? Those patients could be harmed.

Are you someone who might be at increased risk for heart disease if you take calcium supplements. The short answer is we don’t know because previous studies have not asked the right questions.

In my opinion, it is time to pause additional studies and meta-analyses on calcium supplementation and heart health until we have gone over existing studies with a fine-tooth comb to figure out why the results differ so wildly. For example, we need to ask whether the effect of calcium supplements on heart disease risk is influenced by things like:

- Age or ethnicity of participants.

- Other preexisting health conditions.

- Other lifestyle factors (exercise is probably the most important, but others may be involved as well).

- Diet context. For example, we already know that the effect of eggs and dairy on heart health is influenced by diet context. [I have covered this for eggs in a previous issue of “Health Tips From the Professor”.]

- Other unanticipated variables.

Only when we have identified variables that might influence the effect of calcium supplements on heart disease risk, will the scientific community be able to design studies to identify the population groups who might be adversely affected by calcium supplementation.

This would allow health professionals to make informed decisions about which of their patients should avoid calcium supplementation and which of their patients would benefit from calcium supplementation.

2) We really don’t need the recommended RDAs for calcium to build strong bones. The recommended RDAs for calcium are 1,000 mg/day for adults 19-50, 1,000 mg/day for men and 1,200 mg/day for women 51-70, and 1,200 mg/day for both men and women over 70. But do we really need that amount of calcium to build healthy bones?

I have discussed this topic in detail in a previous issue of “Health Tips From the Professor”. Here are the key points:

- The current RDAs are based on calcium needs for people consuming the typical American diet and following the typical American lifestyle. If that is you, the current RDAs probably apply.

- However, strong bones are absolutely dependent on three things, adequate calcium, adequate vitamin D, and adequate weight-bearing exercise. Most recent studies of calcium supplementation and bone density include adequate vitamin D, but almost none of them include exercise. Previous studies have been inadequate.

- The best calcium supplements contain certain nutrients besides vitamin D that optimize bone formation. I have listed those nutrients in the article cited above.

- Our ability to use calcium to build strong bones is dependent on diet (something I call a bone-healthy diet) and lifestyle (something I call a bone-healthy lifestyle).

- For more information on each of these points, read the article I referenced above.

In short, I agree that the current calcium RDAs may be too high for individuals consuming a bone-healthy diet and following a bone-healthy lifestyle. But the current calcium RDAs are likely accurate for people consuming the typical American diet and following the typical American lifestyle.

- While we do not have a calcium RDA for populations following a bone healthy diet lifestyle, some studies suggest that 700-800 mg of calcium/day may be sufficient for this group.

3) Calcium from supplements is absorbed faster and gives higher blood level spikes than calcium from foods. That could be a problem because high blood levels of calcium are associated with calcification of our arteries, which is associated with increased heart disease risk.

This is a theoretical concern, because high blood calcium levels from supplementation are transitory, while it is continuous high blood calcium levels that are associated with calcification of our arteries.

However, it is a plausible concern because most supplement companies design their calcium supplements based on how quickly they get calcium into the bloodstream rather than how effectively the calcium is utilized for bone formation. Here are my recommendations:

- Choose a calcium supplement that provides RDA levels of vitamin D plus other nutrients shown to support strong bone formation.

- Choose a calcium supplement supported by clinical studies showing it is effectively utilized for bone formation.

4) We should be getting our calcium from foods rather than supplements.

While it is always easy for doctors to recommend that we get our nutrients from food rather than supplements, they need to ask whether we are getting those nutrients from our diet. For calcium the data are particularly sobering.

- The average American gets around 740 mg of calcium/day from their diet. That is probably enough for the small percentage of Americans following a bone healthy diet and lifestyle. But it is 260-460 mg short of the 1,000-1,200 mg/day recommended for older adults with the typical American diet and lifestyle.

- - And for the average American, around 70% of their calcium intake comes from dairy foods.
  - So, Americans who are following a typical American diet and lifestyle and are restricting dairy may require 800-1,000 mg/day of supplemental calcium unless they carefully plan their diets to optimize calcium intake.
  - Finally, vegans average about 550 mg/day from their diet. That might be borderline even if they were following a bone healthy lifestyle.

- In short, we cannot assume our diet will provide enough calcium for strong bones unless we include dairy foods and/or plan our diet very carefully. Some degree of supplementation may be necessary.

How Much Calcium Do You Need?

I have covered a lot of territory in this article, so let me summarize the four concerns of the medical community and answer your most important question, “Should you take calcium supplements?”

1) Calcium supplements may increase the risk of heart disease for some people.

That is true, but we have no idea at present who is at increased risk and who isn’t. So, we should minimize our risk by taking the precautions I describe below.

2) We don’t need RDA levels of calcium to build strong bones. That is probably true if you are one of the few people who follows a bone healthy diet and lifestyle, but it isn’t true if you follow the typical American diet and lifestyle.

The current RDAs of 1,000 – 1,200 mg/day are a good guideline for how much calcium you need if you follow the typical American diet and lifestyle.

If you a one of the few people who follow a bone healthy diet and lifestyle (For what that involves, read this article) you may only need 700-800 mg/day. But we don’t have clinical studies that can tell us what the actual RDA for calcium should be under those circumstances.

3) Calcium from supplements is absorbed faster and gives higher blood calcium spikes than calcium from foods. You may remember that the theoretical concern is that even short-term spikes of high blood calcium may lead to calcification of your arteries, which increases your risk of heart disease. So, the important question becomes, “What can we do to minimize these spikes in blood calcium levels?”

We should avoid calcium supplements that brag about how quickly and efficiently the calcium is absorbed. That could lead to calcium spikes. Instead, we should look for calcium supplements that are backed by clinical studies showing they are efficiently utilized for bone formation.

We should look for calcium supplements that include RDA levels of vitamin D and other nutrients that optimize bone formation. You will find more information on that in the same article I referenced above.

Some experts recommend that calcium supplements be taken between meals. But it is probably better to take them with meals because foods will likely slow the rate at which calcium is absorbed and reduce calcium spikes in the blood.

We are told to limit calcium supplements to less than 500 mg at any one time because calcium absorption becomes inefficient at higher doses. It might be even better to limit calcium to 250 mg or less at a time to reduce calcium spikes in the blood.

4) We should get calcium from foods rather than supplements.

Many Americans do not get enough calcium from diet alone, especially if they avoid dairy foods. So, some degree of calcium supplementation may be necessary. I have given some guidelines depending on your diet and lifestyle above.

The amount of supplemental calcium needed is relatively small. I do not recommend exceeding the RDA unless directed to by your health professional.

The Bottom Line

Some studies say that calcium supplements increase heart disease risk while others say they decrease heart disease risk. The headlines veer between “killer calcium” and “beneficial calcium”.

A recent meta-analysis of 12 double-blinded randomized clinical trials with 87,899 participants comparing the effect of a calcium supplement versus a placebo on heart disease outcomes has just been published. This study found no effect of calcium supplementation on:

Heart attack.
Stroke.
Heart failure.
Cardiovascular mortality.
All-cause mortality.

The authors of the study concluded, “Calcium supplementation was not associated with myocardial infraction [heart attack], stroke, heart failure, and cardiovascular/all-cause mortality.

For more details and advice on whether you should follow your doctor’s recommendations for calcium supplementation 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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My posts and “Health Tips From the Professor” articles carefully avoid claims about any brand of supplement or manufacturer of supplements. However, I am often asked by representatives of supplement companies if they can share them with their customers.

My answer is, “Yes, as long as you share only the article without any additions or alterations. In particular, you should avoid adding any mention of your company or your company’s products. If you were to do that, you could be making what the FTC and FDA consider a “misleading health claim” that could result in legal action against you and the company you represent.

For more detail about FTC regulations for health claims, see this link.

https://www.ftc.gov/business-guidance/resources/health-products-compliance-guidance

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About The Author

Dr. Chaney has a BS in Chemistry from Duke University and a PhD in Biochemistry from UCLA. He is Professor Emeritus from the University of North Carolina where he taught biochemistry and nutrition to medical and dental students for 40 years. Dr. Chaney won numerous teaching awards at UNC, including the Academy of Educators “Excellence in Teaching Lifetime Achievement Award”. Dr Chaney also ran an active cancer research program at UNC and published over 100 scientific articles and reviews in peer-reviewed scientific journals. In addition, he authored two chapters on nutrition in one of the leading biochemistry text books for medical students.

Which Diets Are Best In 2023?

February 14, 2023 by Dr. Steve Chaney

Which Diet Should You Choose?

Author: Dr. Stephen Chaney

Many of you started 2023 with goals of losing weight and/or improving your health. In many cases, that involved choosing a new diet. That was only 6 weeks ago, but it probably feels like an eternity.

For many of you the “bloom” has gone off the new diet you started so enthusiastically in January.

Perhaps the diet isn’t working as well as advertised…

Perhaps the diet is too restrictive. You are finding it hard to stick with…

Perhaps you are always hungry or constantly fighting food cravings…

Perhaps you are starting to wonder whether there is a better diet than the one you chose in January…

Perhaps you are wondering whether the diet you chose is the wrong one for you…

If you are rethinking your diet, you might want to know which diets the experts recommend. Unfortunately, that’s not as easy as it sounds. The diet world has become just as divided as the political world.

Fortunately, you have an impartial resource. Each year US News & World Report invites a panel of experts with different points of view to evaluate popular diets. They then combine the input from all the experts into rankings of the diets in various categories.

If you are still searching for your ideal diet, I will summarize the US News & World Report’s “Best Diets In 2023”. For the full report, click on this link.

How Was This Report Created?

US News & World Report recruited a panel of 30 nationally recognized experts in diet, nutrition, obesity, food psychology, diabetes, and heart disease to review the 24 most popular diets.

The diets evaluated are not the same each year. Last year they evaluated the top 40 most popular diets. This year they only reviewed the top 24.

That means some good diets were left off the list. For example, the vegan diet is very healthy, but it is also very restrictive. Very few people follow a pure vegan diet, so it didn’t make the top 24 most popular. However, this year’s list did include several primarily plant-based diets that are more popular with the general public.

The panel is also not the same each year. Some experts are rotated off the panel, and others are added. The experts rate each diet in seven categories:

How easy it is to follow.

Its ability to produce short-term weight loss.

Its ability to produce long-term weight loss.

its nutritional completeness.

Its safety.

Its potential for preventing and managing diabetes.

Its potential for preventing and managing heart disease.

They converted the experts’ ratings to scores 5 (highest) to 1 (lowest). They then used these scores to construct eleven sets of Best Diets rankings:

Best Diets Overall ranks diets on several different parameters, including whether all food groups are included in the diet, the availability of the foods needed to be on the diet and the use of additional vitamins or supplements. They considered if the diet was evidence-based and adaptable to meet cultural, religious, or other personal preferences. In addition, the criteria also included evaluation of the prep and planning time required for the diet and the effectiveness of the diet for someone who wants to get and stay healthy.

Best Plant-Based Diets used the same approach as Best Diets Overall to rank the eight plans emphasizing minimally processed foods from plants that were included in this year’s ratings.

Best Commercial Diet ratings used the same approach to rank 15 commercial diet programs that require a participation fee or promote the use of branded food or nutritional products.

Best Long-Term Weight-Loss Diet ratings were generated by combining the safety of the rate of weight loss promoted and the likelihood of the plan to result in successful long-term weight loss and maintenance of weight loss.

Best Fast Weight-Loss Diets were scored on their effectiveness for someone who wants to lose weight in three months or less.

Best Diabetes Diet ratings were calculated equally from the effectiveness of the diet for someone who wants to lower risk factors for diabetes, the nutritional quality of the diet, and research evidence-based support for the diet.

Best Heart-Healthy Diet ratings were calculated equally from the effectiveness of the diet for someone who wants to lower risk factors for hypertension and other forms of heart disease, the nutritional quality of the diet, and evidence-based support for the diet.

Best Diets for Bone and Joint Health were calculated equally on the effectiveness of the diet for someone who wants to lower their risk factors for inflammation and improve bone and joint health, as well as the nutritional quality and research evidence-based support for the diet.

Best Diets for Healthy Eating combines nutritional completeness and safety ratings, giving twice the weight to safety. A healthy diet should provide sufficient calories and not fall seriously short on important nutrients or entire food groups.

Easiest Diets to Follow represents panelists’ averaged scores for the relevant lifestyle questions, including whether all food groups are included and if the recommended foods are readily available at the average supermarket.

Best Family-Friendly Diets were calculated equally on their adaptability for the whole family, including cultural, religious, and personal preferences, the time required to plan and prep, nutritional value and access to food at any supermarket.

Which Diets Are Best In 2023?

Are you ready? If this were an awards program, I would be saying “Envelop please” and would open the envelop slowly to build suspense.

However, I am not going to do that. Here are the top 3 and bottom 3 diets in each category (If you would like to see where your favorite diet ranked, click on this link.

[Note: I excluded commercial diets from this review. (I have a brief discussion of commercial diets below). If you notice a number missing in my summaries, it is because I eliminated one or more commercial diet from my summary.]

Best Diets Overall

The Top 3:

#1: Mediterranean Diet. The Mediterranean diet has been ranked #1 for 6 consecutive years.

#2 (tie): DASH Diet (This diet was designed to keep blood pressure under control, but you can also think of it as an Americanized version of the Mediterranean diet.)

#2 (tie): Flexitarian Diet (A flexible semi-vegetarian diet).

The Bottom 3:

#20: Keto Diet (A high protein, high fat, very low carb diet designed to achieve ketosis).

#21: Atkins Diet (The granddaddy of the high animal protein, low carb, high fat diets).

#24: Raw Food Diet (A diet based on eating foods that have not been cooked or processed).

Best Plant-Based Diets Overall

The Top 3:

#1: Mediterranean Diet.

#2: Flexitarian Diet.

#3: MIND Diet (This diet is a combination of Mediterranean and DASH but is specifically designed to reduce cognitive decline as we age.)

The Bottom 3:

Since only 8 diets were included in this category, even the bottom 3 are pretty good diets, so I did not include a “list of shame” in this category.

Best Long-Term Weight-Loss Diets

The Top 3:

#1: DASH Diet

#2 (tie): Volumetrics Diet (A diet based on the caloric density of foods).

#2 (tie): Mayo Clinic Diet (A diet designed to establish lifelong healthy eating habits).

The Bottom 3:

#22 (tie): Keto Diet.

#22 (tie): Atkins Diet.

#24: Raw Food Diet.

Best Fast Weight-Loss Diets

The Top 3:

#1: Keto Diet

#2: Atkins Diet

#7 (tie): Mayo Clinic Diet

#7 (tie): South Beach Diet

#7 (tie): Volumetrics Diet

The Bottom 3:

The diets at the bottom of this list were designed for health and weight maintenance rather than rapid weight loss, so I did not include a “list of shame” in this category.

Best Diabetes Diets

The Top 3:

#1: DASH Diet

#2: Mediterranean Diet

#3: Flexitarian Diet

The Bottom 3:

#20: Atkins Diet

#21: Paleo Diet (A diet based on what our paleolithic ancestors presumably ate. It restricts grains and dairy and is heavily meat-based).

#22: Raw Food Diet.

Best Heart-Healthy Diets

The Top 3:

#1: DASH Diet

#2: Mediterranean Diet

#3 (tie): Ornish Diet (A whole food, semi-vegetarian diet designed to promote heart health).

#3 (tie): Flexitarian Diet

The Bottom 3:

#22 (tie): Raw Foods Diet

#22 (tie): Paleo Diet

#24: Keto Diet

Best Diets for Bone and Joint Health

The Top 3:

#1 (tie): DASH Diet

#1 (tie): Mediterranean Diet

#3: Flexitarian Diet

The Bottom 3:

#21 (tie): Raw Foods Diet

#21 (tie): Paleo Diet

#22: Atkins Diet

#23: Keto Diet

Best Diets for Healthy Eating

The Top 3:

#1: Mediterranean Diet

#2: DASH Diet

#3: Flexitarian Diet

The Bottom 3:

#22: Keto Diet

#23: Atkins Diet

#24: Raw Foods Diet

Easiest Diets to Follow

The Top 3:

#1 (tie): Flexitarian Diet

#1 (tie): TLC Diet (This diet was designed by the NIH to reduce cholesterol levels and promote heart health.)

#3 (tie): Mediterranean Diet

#3 (tie): DASH Diet

The Bottom 3:

#19: Atkins Diet

#20: Keto Diet

#22: Raw Foods Diet

Which Diets Are Best For Rapid Weight Loss?

There are 2 take-home lessons from the rapid weight loss category:

If you are looking for rapid weight loss, any whole food restrictive diet will do.

- Last year’s diet analysis included the vegan diet, and both vegan and keto diets ranked near the top of the rapid weight loss category. Keto and vegan diets are both very restrictive, but they are polar opposites in terms of the foods they allow and restrict.

- - The keto diet is a meat heavy, very low carb diet. It restricts fruits, some vegetables, grains, and most legumes.

- - The vegan diet is a very low-fat diet that eliminates meat, dairy, eggs, and animal fats.

- The Atkins and keto diets toppled this year’s rapid weight loss list, but they were joined by the Mayo Clinic, South Beach, and volumetrics diets. Those diets are also restrictive, but, like the vegan diet, they are very different from the Atkins and keto diets.

- I did not include commercial diets that rated high on this list, but they are all restrictive in one way or another.

2) Whole food, very low carb diets like Atkins and keto are good for rapid weight loss, but they rank near the bottom of the list for every healthy diet category.

- If you choose to lose weight on the Atkins or keto diets, switch to a healthier diet once you reach your desired weight loss.

Which Diet Should You Choose?

With rapid weight loss out of the way, let’s get back to the question, “Which Diet Should You Choose?” My recommendations are:

1) Choose a diet that fits your needs. That is one of the things I like best about the US News & World Report ratings. The diets are categorized. If your main concern is diabetes, choose one of the top diets in that category. If your main concern is heart health… You get the point.

2) Choose diets that are healthy and associated with long term weight loss. If that is your goal, you will notice that primarily plant-based diets top these lists. Meat-based, low carb diets like Atkins and keto are near the bottom of the lists.

“Why is that?”, you might ask? The answer is simple. And it’s not that all 30 experts were prejudiced against low carb diets. It’s that the major primarily plant-based diets like Mediterranean, DASH, and flexitarian are backed by long-term clinical studies showing they are healthy and significantly reduce the risk of diabetes, heart disease, and other chronic diseases.

On the other hand, there are no long-term studies showing the Atkins and keto diets are healthy long term. And since the Atkins diet has been around for more than 50 years, the lack of clinical evidence that it is healthy long term is damming.

3) Choose diets that are easy to follow. The less-restrictive primarily plant-based diets top this list – diets like Mediterranean, DASH, MIND, and flexitarian. They are also at or near the top of almost every diet category.

4) Choose diets that fit your lifestyle and dietary preferences. For example, if you don’t like fish and olive oil, you will probably do much better with the DASH or flexitarian diet than with the Mediterranean diet.

5) Finally, focus on what you have to gain, rather than on foods you have to give up.

On the minus side, none of the diets include sodas, junk foods, and highly processed foods. These foods should go on your “No-No” list. Sweets should be occasional treats and only as part of a healthy meal. Meat, especially red meat, should become a garnish rather than a main course.

On the plus side, primarily plant-based diets offer a cornucopia of delicious plant foods you probably didn’t even know existed. Plus, for any of the top-rated plant-based diets, there are websites and books full of mouth-watering recipes. Be adventurous.

What About Commercial Diets?

I chose not to review commercial diets by name, but let me make a few observations.

If you look at the gaps in my lists, it should be apparent that several commercial diets rank near the top for fast weight loss, but near the bottom on most healthy diet lists.

I do not recommend commercial diets that rely on ready-to-eat, low-calorie, highly processed versions “of your favorite foods”.

- These pre-packaged meals are expensive. Unless you are a millionaire, you won’t be able to afford these meals for the rest of your life.

- These pre-packaged meals are not teaching you healthy eating habits that will allow you to keep the weight off.

If you wish to spend your hard-earned dollars on a commercial diet, choose a diet that:

- Relies on whole foods from all 5 food groups.

- Teaches and provides support for the type of lifestyle change that leads to permanent weight loss.

Meal replacement shakes can play a role in healthy weight loss if:

- They are high quality and use natural ingredients as much as possible.

- They are part of a holistic lifestyle change program.

The Bottom Line

For many of you the “bloom” has gone off the new diet you started so enthusiastically in January. If you are rethinking your diet, you might want to know which diets the experts recommend. Unfortunately, that’s not as easy as it sounds. The diet world has become just as divided as the political world.

There are probably two questions at the top of your list.

#1: Which diets are best for rapid weight loss? Here are 2 general principles:

If you are looking for rapid weight loss, any whole food restrictive diet will do.

2) If you choose to lose weight on the Atkins or keto diets, switch to a healthier diet once you reach your desired weight loss. Atkins and keto diets are good for rapid weight loss, but they rank near the bottom of the list for every healthy diet category.

#2: Which diet should you choose? Here the principles are:

Choose a diet that fits your needs.

2) Choose diets that are healthy and associated with long term weight loss.

3) Choose diets that are easy to follow.

4) Choose diets that fit your lifestyle and dietary preferences.

5) Finally, focus on what you have to gain, rather than on foods you have to give up.

For more details on the diet that is best for you and my thoughts on commercial diets, read the article above.

Are Vegan Diets Bad For Your Bones?

May 25, 2021 by Dr. Steve Chaney

The Secrets To A Healthy Vegan Diet

Author: Dr. Stephen Chaney

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.

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

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

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

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

How Was This Study Done?

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

Vegan diets were defined as excluding all animal foods.

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

Omnivore diets were defined as including both plant and animal foods from every food group.

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

Are Vegan Diets Bad For Your Bones?

Here is what the investigators found:

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

Lumbar spine:

- Vegans and vegetarians combined had a 3.2% lower bone density than omnivores.

- The effect of diet was stronger for vegans (7% decrease in bone density) than it was for vegetarians (2.3% decrease in bone density).

Femoral neck:

- Vegans and vegetarians combined had a 3.7% lower bone density than omnivores.

- The effect of diet was stronger for vegans (5.5% decrease in bone density) than it was for vegetarians (2.5% decrease in bone density).

Whole body:

- Vegans and vegetarians combined had a 3.2% lower bone density than omnivores.

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

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

Vegans and vegetarians combined had a 32% higher risk of bone fractures than omnivores.

The effect of diet on risk of bone fractures was statistically significant for vegans (44% higher risk of bone fracture) but not for vegetarians (25% higher risk of bone fractures).

These data suggest the decreased bone density in vegans is clinically significant.

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

The Secrets To A Healthy Vegan Diet

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

- Healthy vegan foods that can be bad for your bones include.

- - Pinto beans, navy beans, and peas because they contain phytates.

- - Raw spinach & swiss chard because they contain oxalates.

- - Both phytates and oxalates bind calcium and interfere with its absorption.

- - These foods can be part of a healthy vegan diet, but a vegan expert consumes them in moderation.

- Unhealthy “vegan” foods that are bad for your bones include sodas, salt, sugar, and alcohol.

- - The mechanisms are complex, but these foods all tend to dissolve bone.

- - A vegan expert minimizes them in their diet.

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

- None of the studies included in this meta-analysis measured how much exercise the study participants were getting.

- The individual studies were generally carried out in industrialized countries where many people get insufficient exercise.

- The DV for calcium in the United States is 1,000-1,200 mg/day for adults. In more agrarian societies dietary calcium intake is around 500 mg/day, and osteoporosis is almost nonexistent. What is the difference? These are people who are outside (vitamin D) doing heavy manual labor (exercise) in their farms and pastures every day.

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

The Bottom Line

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

Do vegans have lower bone density than omnivores?

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

The study found that:

Vegans had 5.5%–7% lower bone density than omnivores depending on where the bone density was measured.

Vegans were 44% more likely to suffer from bone fractures than omnivores.

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

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

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

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

Is Vitamin D Overhyped?

April 23, 2014 by Dr. Steve Chaney

Are Clouds Gathering For the Sunshine Vitamin?

Author: Dr. Stephen Chaney

We’ve known for years that vitamin D plays an essential role in calcium metabolism and is important for bone health. In fact, the use of vitamin D to prevent and cure rickets is one of the greatest success stories in the field of nutrition.

However, in recent years a number of studies have suggested that adequate vitamin D status was also important in reducing the risk of cancer, heart disease, diabetes, infectious diseases and autoimmune diseases – as well as overall mortality. Suddenly it seemed as if vitamin D could leap over tall buildings in a single bound (I realize that I’m probably dating myself with that analogy).

So when I saw the headlines about a new study (Theodoratou et al, BMJ, 2014;348:g2035 doi: 10.1136/bmj.g2035) that concluded all of those benefits of vitamin D were unconfirmed, I was not surprised. After all there have been many examples of periods in which individual vitamins were reported to have miraculous benefits – only to have most of those benefits debunked by subsequent studies. I fully expected that would be the theme of this issue of “Health Tips From the Professor”.

But when I read the article I found that the study had multiple flaws (more about that latter). I also discovered that the same issue of the British Medical Journal had another, much better designed, study that came to the exact opposite conclusion (Chowdhury et al, BMJ 2014;348:g1903 doi: 10.1136/bmj.g1903).

Funny how only the first study made it into the headlines. It’s only the negative news that sells.

Is Vitamin D Overhyped?

The first study was a very large meta-analysis that included 107 systematic reviews, 74 meta-analyses of observation studies (studies that compare population groups) and 87 meta-analyses of randomized, placebo controlled trials. In case you were wondering, the total number of patients enrolled in these studies must have numbered in the hundreds of thousands.

The authors of the study reported that:

There was no relationship between vitamin D intake and cancer, heart disease, autoimmune disease, infectious diseases, diabetes and other diseases. In other words, they concluded that most of the recent excitement about vitamin D was just hype.

There was also no evidence that vitamin D increased bone density or reduced the risk of fractures and falls in older people – in contrast to many previous studies.

Based on this evidence the authors said “universal conclusions about vitamin Ds benefits cannot be drawn [from current data]” and that vitamin D “might not be as essential as previously thought in maintaining bone mineral density”.

Both of those statements are pretty revolutionary, but a study this large has to be true – right? The answer is a definite maybe. The problem is that many of the studies included in this meta-analysis were poorly designed by today’s standards. Remember the old saying “garbage in, garbage out”.

The Study Is Flawed

My specific criticisms of the study are:

1) The conclusions about vitamin D and bone density were seriously flawed. The authors acknowledged that previous studies have shown that calcium and vitamin D together increased bone density, but they considered calcium to be a confounding variable and only included clinical trials using vitamin D supplementation alone. That shows a complete misunderstanding of the biochemical role of vitamin D.

The purpose of vitamin D is to maintain constant levels of blood calcium, not to build strong bones.

When blood levels of calcium are high, vitamin D lowers it by depositing the calcium in bones.
When blood levels of calcium are low, vitamin D raises it by leaching calcium from bone.

That’s why vitamin D and calcium work together. It is utter nonsense to expect vitamin D to increase bone density or prevent fractures unless you make sure that calcium intake is at least adequate.

2) Most studies of vitamin D supplementation did not stratify the data based on low versus high levels of 25-hydroxy vitamin D at the beginning of the study. That’s important because you would only expect vitamin D supplementation to be of benefit in people with low levels of 25-hydroxy vitamin D to begin with. If their 25-hydroxy vitamin D levels are already optimal, vitamin D supplementation is unlikely to be of additional benefit.

3) Finally, the authors did not separate the studies based on whether vitamin D2 or vitamin D3 was used. That’s important because some recent studies have suggested that D3 is more beneficial than D2.

Is Vitamin D Beneficial After All?

The second study came to the exact opposite conclusions. It was also a very large study. It included 73 observational studies (849,412 participants) and 22 randomized, placebo controlled studies (30,716) participants. Here is what the authors of this study concluded.

High blood levels of 25-hydroxy vitamin D decreased the risk of heart disease by 35%, cancer by 14% and overall mortality by 35%.

Supplementation with vitamin D3 reduced overall mortality by 11%, while supplementation with vitamin D2 increased overall mortality by an insignificant 4%.

65% of the US population can be classified as vitamin D insufficient (blood levels of 25-hydroxy vitamin D of below 30 ng/ml) and 4% as severely deficient in vitamin D (blood levels below 10 ng/ml)

Vitamin D deficiency contributes to 13% of the deaths in the United States. For comparison the corresponding numbers for other major risk factors are: smoking – 20%, physical inactivity – 11% and alcohol – 9%.

About the only point on which the two studies agreed was that there is a need for more, better designed studies to clarify the benefits of vitamin D.

The Bottom Line:

1) Two studies were published in the April 2014 issue of the British Medical Journal. The first concluded that all of the supposed benefits of vitamin D – including increasing bone density – were not supported by the available data. The second study concluded that adequate intake of vitamin D significantly reduced deaths due to heart disease and cancer and also significantly reduced overall mortality. Somehow, only the first study made it into the headlines. Why does that not surprise me?

2) The suggestion in the first study that vitamin D may not be essential for strong bones is based on a complete misunderstanding of the role of vitamin D in the body. There are ample clinical studies showing that vitamin D and calcium together are essential for strong bones. Nobody who understands biochemistry would expect vitamin D to increase bone density in the absence of calcium, but the authors only considered studies that excluded calcium in drawing their conclusion that vitamin D did not increase bone density.

3) The only point of agreement between the two studies is that more and better studies are needed to sort out the benefits of vitamin D and what levels of vitamin D are optimal. I wholeheartedly agree.

4) My advice is to ignore the headlines telling you that vitamin D is dead. On the other hand, don’t get caught up in the hype and buy megadoses of vitamin D supplements. While the evidence is rock solid that vitamin D and calcium together are essential for strong bones, the jury is still out on some of the other health benefits of vitamin D.

5) If you are supplementing with vitamin D you should know that the RDAs for vitamin D are 600 IU for ages 1-70 and 800 IU over 70. The safe upper limit has been set at 4,000 IU. You should only go above that on a doctor’s advice.

6) However, people metabolize vitamin D with different efficiencies, so I strongly recommend that you get your blood levels of 25-hydroxy vitamin D tested and let your doctor help you determine how much vitamin D you should be getting.

7) Finally, a number of recent studies suggest that vitamin D3 may be more effective than vitamin D2, so I only recommend supplements that contain D3.

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.