calcium

What Nutrients Are Missing In Prenatal Supplements?

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Do These Deficiencies Matter?

Author: Dr. Stephen Chaney

healthy pregnancyIf you are a pregnant mom, nothing is more important than the health of your baby. And if you are pregnant or thinking of becoming pregnant, your doctor has probably recommended a prenatal supplement. But does the prenatal supplement he or she recommended provide you with all the nutrients you need?

In a previous issue of “Health Tips From the Professor” I shared two studies that suggested the answer is, “No”. Those studies concluded that most prenatal supplements had little or no vitamin K, choline, DHA, and iodine – all of which are essential for the health of your newborn baby. And while most prenatal supplements contained calcium, the amount they provided was far below recommended levels.

The authors of the first study also made the point that most women going on a prenatal supplement will probably discontinue taking their multivitamin supplement, so a good prenatal supplement should provide all the essential nutrients.

But they don’t. Folic acid, iron, calcium, and vitamin D have long been recognized as essential for a healthy pregnancy. So, virtually every prenatal supplement contained these four nutrients, although calcium is often present in suboptimal amounts. Beyond those four nutrients, the design of prenatal supplements is haphazard. Some contain vitamin K, choline, iodine, or DHA (often in suboptimal amounts). But almost none contain all four nutrients.

And when you consider the other essential nutrients you find in most multivitamins, prenatal supplements often come up empty. Is that a problem? That’s what this study (KM Godfrey et al, PLOS Medicine, 1-27, December 5, 2023) was designed to find out.

How Was This Study Done?

clinical studyThis was a double-blind, placebo-controlled clinical trial, the gold standard for clinical studies. The investigators recruited 1,729 women who were planning to get pregnant from England, Singapore, and New Zealand between 2015 and 2017.

The women were randomly split into two groups:

  • The control group received a supplement containing nutrients that were most frequently included in prenatal supplements in those countries (folic acid, iron, calcium, iodine, and beta-carotene).
  • The intervention group received a supplement containing those nutrients plus riboflavin, vitamin B6, vitamin B12, vitamin D, zinc, inositol, and probiotics).
  • Riboflavin, vitamin B6, vitamin B12, vitamin D, and zinc were included because they are included in most multivitamins but are often missing in prenatal supplements.
  • Inositol was included because some studies have suggested that inositol may reduce the risk of maternal hyperglycemia and gestational diabetes.

Blood samples to assess nutritional status were obtained from all women in the study before the trial started (baseline) and after 1 month of supplementation with either the control or intervention formulation.

Of the women entering the study, 512 went on to have a singleton (one child) pregnancy. For these women supplementation was continued until childbirth. Additional blood samples were obtained in early and late pregnancy and at 6 months postdelivery. [Note: no supplementation was provided to either group postdelivery. And this is also a period of time when most women would be breastfeeding.]

The blood samples were tested for:

  • Blood levels of folic acid, riboflavin, vitamin B6, vitamin B12, and vitamin D.
  • Functional biomarkers of deficiencies of each of these vitamins.

What Nutrients Are Missing In Prenatal Supplements?

Question MarkThere was no difference in maternal hyperglycemia or gestational diabetes between the control group and the intervention group supplemented with inositol, so I will focus on the other nutrients present in the intervention group.

At baseline when subjects were first entered into the study.

  • 29.2% of the subjects had low or marginal status for folic acid.
  • 82.0% of the subjects had low or marginal status for riboflavin.
  • 1.3% of the subjects had low or marginal status for vitamin B6.
  • 9.1% of the subjects had low or marginal status for vitamin B12.
  • 48.7% of the subjects had low or marginal status for vitamin D.
  • 91.0% of the subjects had low or marginal status for one or more of these vitamins.

In the control group receiving folic acid but no riboflavin, vitaminB6, vitamin B12, and vitamin D:

  • Folic acid deficiency fell to 4.1% after 1 month of supplementation (the supplement used by the control group contained folic acid), 1% in early pregnancy, 6.1% in late pregnancy, and rose to 31.8% 6 months after supplementation was discontinued. The intervention group got the same amount of folic acid, and their results were similar.
  • Riboflavin deficiency ranged from 82-92% during pregnancy and returned to 82% 6 months postdelivery.
  • Vitamin B6 deficiency increased to 54% in late pregnancy and returned to 1.2% 6 months postdelivery.
  • Vitamin B12 deficiency increased to 55% in late pregnancy and returned to 12.4% 6 months postdelivery.
  • Vitamin D deficiency ranged from 35-43% during pregnancy and returned to 31% 6 months postdelivery.
  • Functional markers of vitamin B6 deficiency were evident by late pregnancy.

In short, data from the control group fell into 3 categories:

  • The data with folic acid confirm previous studies showing that folic acid in the amount present in most prenatal supplements is effective at preventing folic acid deficiency before and during pregnancy. It also strengthens the argument for continuing folic acid supplementation during breastfeeding.
  • Deficiencies of riboflavin and vitamin D are prevalent in women of childbearing age, but pregnancy does not appear to significantly impact the percentage of women who are deficient in these nutrients.
  • Deficiencies of vitamins B6 and B12 are rare in women of childbearing age, but pregnancy significantly depletes both nutrients.
    • This was particularly evident for vitamin B6. Blood levels of vitamin B6 markers decreased to a level that could impact the functioning of vitamin B6-depended metabolic pathways.

pregnant women taking vitaminsFor the intervention group receiving additional riboflavin, vitamin B6, vitamin B12, and vitamin D:

  • Deficiencies of these vitamins were eliminated by one month of supplementation.
  • Vitamin levels remained adequate during pregnancy.
  • Except for vitamin B12, deficiencies of these vitamins reappeared when supplementation was discontinued for 6 months. The maintenance of adequate B12 levels 6 months after supplementation stopped was expected because the body holds on to its B12 stores very tightly.

In short deficiencies of these nutrients before and during pregnancy could be eliminated by supplementation with levels of these nutrients found in many multivitamins.

The authors concluded, “Over 90% of the trial participants had low concentrations of one or more of folate, riboflavin, vitamin B12, or vitamin D during preconception, and many developed markers of vitamin B6 deficiency in late pregnancy. Preconception/pregnancy supplementation in amounts available in over-the-counter supplements substantially reduces the prevalence of vitamin deficiency and depletion markers before and during pregnancy, with higher maternal plasma vitamin B12 maintained during the recommended lactation period.”

Do These Deficiencies Matter?

New ParentsIt is well established that deficiencies of folic acid and vitamin D cause health risks for the mother and developmental risks for the fetus, so I won’t discuss these nutrients here.

However, the effect of riboflavin, vitamin B6, and vitamin B12 deficiencies on pregnancy is less well known, which is probably why these nutrients are often not added to prenatal supplements.

The authors of the study said small studies have suggested that:

  • Low or deficient riboflavin status may be associated with a higher risk of anemia during pregnancy.
  • Low vitamin B6 status may be associated with an increased risk of preterm birth and development of metabolic health risks in the child.
  • Low vitamin B12 status may be associated with increased risk of gestational diabetes and pre-eclampsia in the mother, and increased risk of neural tube defects, preterm birth, low birth weight, and neurocognitive delays in the baby – with the strongest evidence being an effect on neurocognitive development.

While none of these risks have been definitively proven, the authors point out that deficiencies of these nutrients can easily be eliminated with inexpensive, over-the-counter multivitamin supplements.

What Does This Study Mean For You?

Questioning WomanPerhaps I should start this section by asking why these deficiencies are so common in women of child-bearing age.

The authors speculate that part of the reason is that many women are giving up meat (B12 and iron) and dairy (calcium and riboflavin) for health or environmental reasons.

However, they also point out that a more likely cause is that more than 60% of calories consumed in countries like England, New Zealand, and the United States comes from ultra-processed foods – otherwise known as “empty calories”.

Whatever the cause, the authors conclude, “…the findings suggest a need to reappraise dietary recommendations for preconception and pregnancy to consider further the role of multiple micronutrient supplements for women living in higher-income countries.” I agree.

In a previous “Health Tips From the Professor” article, I reported a recent study showing that most prenatal supplements have either no or inadequate amounts of vitamin K, choline, DHA, iodine, and calcium, nutrients that are absolutely essential for a healthy pregnancy. And I gave recommendations for choosing the best prenatal supplement for you and your child.

That study also noted that many women discontinue their multivitamin supplement when they start taking a prenatal supplement. The current study indicates that practice may be unwise. It shows that:

  • Many women of childbearing age are deficient in one or more of these essential nutrients, and…
  • Essential nutrients not found in most prenatal supplements may also be important for a healthy pregnancy.

So, if you are pregnant or thinking of becoming pregnant, follow this article’s recommendation to start with a well-designed prenatal supplement that provides adequate amounts of folate, iron, calcium, vitamin D, vitamin K, choline, DHA, and iodine and add a multivitamin supplement that provides the other essential nutrients. Alternatively, a simpler approach would be to choose a well-designed prenatal supplement that includes all the essential nutrients. That would be my recommendation.

I would also note this study showed that deficiencies of most of these nutrients reappeared as soon as supplementation was discontinued. Although the authors of this study did not mention it, this reinforces the importance of continuing supplementation during breastfeeding.

The Bottom Line

I have previously reported on a study that concluded many prenatal supplements lack one or more nutrients shown to be important for a healthy pregnancy. But let’s say you have found a prenatal supplement that provides all those nutrients. Is that enough?

Studies show that most women stop taking their multivitamin supplement when they start on a prenatal supplement. But is that a good idea? Are there essential nutrients found in multivitamins, but not in many prenatal supplements that are also important for a healthy pregnancy?

A recent study asked that question in women who were trying to become pregnant. The study found that:

  • Many women of childbearing age are deficient in one or more essential nutrients found in multivitamin supplements but often missing in prenatal supplements, and…
  • Essential nutrients not found in most prenatal supplements may also be important for a healthy pregnancy.

For more details about this study and what it means 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.

 ______________________________________________________________________________

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

 ______________________________________________________________________

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.

Since retiring from the University of North Carolina, he has been writing a weekly health blog called “Health Tips From the Professor”. He has also written two best-selling books, “Slaying the Food Myths” and “Slaying the Supplement Myths”. And most recently he has created an online lifestyle change course, “Create Your Personal Health Zone”. For more information visit https://chaneyhealth.com.

For the past 45 years Dr. Chaney and his wife Suzanne have been helping people improve their health holistically through a combination of good diet, exercise, weight control and appropriate supplementation.

Are Calcium Supplements Heart Healthy?

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

Author: Dr. Stephen Chaney

Heart ConfusionAre 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?

Clinical StudyThe 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?

calcium supplementsThis 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?

Doctor With PatientAs 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 Healthy Bonerecommended 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. dairy foods

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?

Questioning Woman

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”.

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.

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.

 _____________________________________________________________________________

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

____________________________________________________________________

About The Author

Dr. Steve ChaneyDr. 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.

 

Is Vegan Breast Milk Sufficient?

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What Can Vegan Moms Do?

Author: Dr. Stephen Chaney 

breastfeedingA whole food vegan diet is incredibly healthy:

  • Vegans are less likely to be overweight than the general population.
  • Vegans have a lower risk of diabetes, heart disease, cancer, hypertension, and several other diseases than the general population.
  • Whole food vegan diets are anti-inflammatory, so they lower the risk of autoimmune diseases and the “itis” diseases.

But vegan diets leave out meat, dairy, and eggs. Vegetarians without proper dietary advice are at high risk of inadequate intake of vitamin B12, vitamin D, iron, iodine, calcium, and DHA. And, of course, the risk of inadequate intake is even greater for vegans than it is for vegetarians, who may include some dairy and eggs in their diet.

So, it is legitimate to ask whether a vegetarian or vegan diet is sufficient for pregnancy and lactation. The short answer is that they can be if they are properly designed and properly supplemented.

But that is not an easy task, as evidenced by a recent study (N Ureta-Velasco et al., Nutrients 15:1855, 2023) comparing the breast milk of omnivore moms with the breast milk of vegetarian and vegan moms.

How Was This Study Done?

clinical studyThis study was done with 92 omnivore moms, 9 vegetarian moms (5-ovo-vegetarian and 4 lacto-ovo-vegetarians) and 11 vegan moms between August 2017 and February 2020 at the Regional Human Milk Bank at the “12 de Octubre” University Hospital in Madrid, Spain. The vegetarian and vegan moms were grouped together for data analysis.

On Day 0 of the study, participants went to the regional milk bank for blood and urine samples to determine nutritional status, a screening to determine health and socioeconomic status, and for food frequency questionnaire to characterize their habitual diet.

On days 1-5, they returned to the regional milk bank with a 24-hour diet recall of the previous day and to express 25 ml of breast milk to determine its nutrient content. On day 6, they returned to express a larger sample of breast milk to determine its lipid content (including EPA and DHA).

Note: Both the food frequency questionnaire and the 24-hour dietary recalls included nutrients derived from supplements.

What Did The Study Show About Dietary Intake of Key Nutrients?

Questioning WomanThis was a comprehensive study, so I will just cover the highlights here:

Birth Weight: Compared to the children of omnivore moms, the children of vegetarian/vegan moms were more likely to:

  • Have less weight gain during pregnancy (2 pounds less on average).
  • Be underweight at birth (60% of babies born to vegetarian/vegan moms were in the underweight category of birth weights versus 25% for babies born to omnivore moms).

This is probably because vegetarian/vegan moms:

  • Consumed slightly fewer calories per day (2146 versus 2319).
  • Consumed significantly less protein (67 g/d versus 96 g/d).
  • Were 10 times more likely to be underweight prior to pregnancy (10% versus 1%).

This is a concern because low birth weight increases the risk of physical and mental health issues later in life.

Supplement Use: The nutrients of greatest concern in a vegetarian/vegan diet are vitamin B12, vitamin D, iron, iodine, calcium, and DHA. For all these nutrients except DHA, this message appears to have gotten out to most vegetarian/vegan mothers because they were compensating for these potential deficiencies through supplementation.

For example, when they looked at average daily intake of these key nutrients from supplements, they found:

Nutrient Vegetarian/Vegan Moms Omnivore Moms
Vitamin D 1,080 IU (27mcg) 240 IU (6 mcg)
Folic acid 400 mcg 280 mcg
Vitamin B12 312 mcg 2 mcg
Calcium 566 mg 164 mg
Iron 40 mg 29 mg
DHA 100 mg 180 mg

However, that doesn’t tell the whole story, because not all vegetarian/vegan moms took supplements. When the investigators looked at the percent taking supplements, this is what they found.

Nutrient Vegetarian/Vegan Moms Omnivore Moms
Vitamin D 50% 50%
Folic acid 35% 61%
Vitamin B12 85% 60%
Calcium 15% 37%
Iron 25% 43%
DHA 10% 16%

Dietary Intake (Food + Supplements): The extra supplementation clearly played an important role because when the investigators looked at the overall intake from food and supplements, they found:

Nutrient Vegetarian/Vegan Moms Omnivore Moms
Vitamin D 224 IU (5.6 mcg) 432 IU (10.8 mcg)
Folate + Folic acid 668 mcg 473 mcg
Vitamin B12 258 mcg 6.9 mcg
Calcium 910 mg 1148 mg
Iron 31 mg 25 mg
DHA 110 mg 380 mg

Again, this doesn’t tell the whole story. Some women didn’t supplement. When the investigators looked at the percentage of women getting an inadequate intake of key nutrients from food plus supplements they found:

Nutrient Vegetarian/Vegan Moms Omnivore Moms
Vitamin D 75% 88%
Folate + Folic acid 0% 39%
Vitamin B12 25% 0%
Calcium 45% 40%
Iron Not reported Not reported
DHA Not reported Not reported

These results clearly show the need for supplementation. While the average intake from food plus supplements looked good, there were a significant percentage of women who weren’t getting adequate intake of key nutrients because they didn’t supplement.

The exceptions were folate + folic acid for vegetarian/vegans because their diet is rich in folate-containing foods and vitamin B12 for omnivores because their diet is rich in foods containing B12.

Is Vegan Breast Milk Sufficient?

Of course, the proof is in the pudding. When the investigators looked at the nutrient content of breast milk, this is what they found:

Nutrient Vegetarian/Vegan

Moms

 Omnivore

Moms

 Reference

Value*
Vitamin D3 1.1 mcg/L 3.4 mcg/L 0.25-2 mcg/L
Folate + Folic acid 19 mcg/L 20 mcg/l 80 mcg/L
Vitamin B12 0.74 mcg/L 0.65 mcg/L 0.5 mcg/L
Calcium 83 mg/L 99 mg/L 200-300 mg/L
Iron Not reported Not reported
DHA 0.15 g/100 g fat 0.33 g/100 g fat 0.35 g/100 g fat

*Reference values established by WHO

  • The chief difference between breast milk from vegetarian/vegan moms was in DHA levels.
  • That’s because the diet of vegetarians and vegans contains very little DHA, and very few vegetarian/vegan women in this study supplemented with DHA.
  • This study also found that breast milk from both vegetarian/vegan moms and omnivore moms was low in folate + folic acid, calcium, nicotinamide, and selenium. They said that requires follow-up in future studies.

The authors concluded, “The most important contribution of this study is the detailed and comprehensive description of micronutrients and lipids in human milk from omnivore milk donors and vegetarian/vegan women…Of particular concern is the lower DHA content in the milk of our vegetarian/vegan group. However, raising awareness and administering proper supplementation could bridge the gap, as has been the case with vitamin B12.”

What Can Vegan Moms Do?

This study emphasizes the importance of careful planning and supplementation during pregnancy and lactation if you are a vegetarian or vegan mom.

For example, the vegetarian/vegan women in this study were more likely to have low birthweight babies, and low birthweight infants are at risk for health issues later in life. That means:

  • Careful planning is required to select calorie- and protein-rich plant foods.
  • A high-quality plant protein supplement can be a great help.

Supplementation is particularly important during lactation to assure your breast milk adequately nourishes your newborn baby. For example, in this study:

  • The vitamin B12 level in the breast milk from vegetarian/vegan moms was adequate because 85% of them supplemented with vitamin B12.
  • The DHA level in the breast milk from vegetarian/vegan moms was inadequate because only 10% of them supplemented with DHA.
  • The authors of this study recommended that vegetarian and vegan moms consume at least 200 mg of DHA from algal sources while they are breastfeeding.

However, finding a prenatal supplement that provides all the nutrients you need prior to pregnancy, during pregnancy, and while breastfeeding is challenging. I gave you 7 tips for choosing the best prenatal supplements in a previous “Health Tips From the Professor” article.

The Bottom Line 

A recent study asked whether the breast milk of vegetarian and vegan moms was sufficient for the needs of their newborn babies. The study found that:

  • Folate levels in their breast milk were sufficient because the diets of vegetarians and vegans contain many folate-rich foods.
  • Vitamin B12 levels in their breast milk were sufficient because 85% of the vegetarian and vegan women in this study supplemented with vitamin B12.
  • DHA levels in their breast milk were insufficient because the diets of vegetarian and vegan women are very low in DHA, and only 10% of the women in this study supplemented with DHA.
  • The authors of this study recommended that vegetarian and vegan moms consume at least 200 mg of DHA from algal sources while they are breastfeeding.

This study reinforces the need for supplementation during lactation to assure your breast milk adequately nourishes your newborn baby.

However, finding a prenatal supplement that provides all the nutrients you need prior to pregnancy, during pregnancy, and while breastfeeding is challenging. I gave you 7 tips for choosing the best prenatal supplement in a previous “Health Tips From the Professor” article.

For more information on this study 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.

___________________________________________________________________________

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

 

 

Prenatal Supplements Strike Out Again

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Is It Three Strikes And You Are Out?

Author: Dr. Stephen Chaney

Pregnant CoupleIf you are pregnant, you want the best for your unborn baby. Your doctor has recommended a prenatal supplement, but do the prenatal supplements on the market meet your needs? A few months ago, I shared two studies that concluded that most prenatal supplements on the market are woefully inadequate.

In fact, the authors said, “[Our] analysis found that prenatal supplements vary widely in content, often only contain a subset of essential vitamins, and the levels were often below…recommendations.”

In other words, their study found that most prenatal vitamins on the market may not be adequate to support your needs and the needs of your child through pregnancy and breastfeeding.

Now, a third study on the topic has been published (KA Saunders et al, American Journal of Clinical Nutrition, 117: 823-829, 2023. It differs from the previous studies in that:

1) The previous two studies took a comprehensive approach, while this study focused on 6 key nutrients.

  • The previous studies included all nutrients important for a healthy pregnancy including choline, iodine, and vitamin K, which have only recently been shown to be important for a healthy pregnancy.
  • This study focused on 6 nutrients, vitamin A, vitamin D, folic acid, calcium, iron, and omega-3 fatty acids, which have long been recognized as essential for a healthy pregnancy.

2) The previous two studies focused on prenatal supplements, while this study focused on all supplements that might be taken by pregnant women.

3) The previous two studies asked whether supplements provided recommended amounts of all nutrients needed for a healthy pregnancy. This study took a “Goldilocks approach” and asked whether levels of these 6 essential nutrients were appropriate (“just right”). The study:

  • Started by determining the intake of these 6 key nutrients by American women. The authors of the study then added the amount of each nutrient provided by the supplements in their study to the amount of that nutrient in the diet of American women and:
    • Calculated the minimum amount of each nutrient that would be needed to assure that 90% of American women taking a particular supplement would meet the recommended intake for pregnant and lactating women.
    • Calculated the maximum amount of each nutrient provided by supplements in their study to assure that that 90% of American women taking that supplement would not get potentially toxic amounts of that nutrient.
  • In other words, for each of the 6 nutrients they calculated a supplemental dose range that was neither too low nor too high. They called this the “appropriate dose range” for each nutrient. Goldilocks would have called it “just right”.

I’m sure you are anxiously waiting to learn what their study found. But before we go there, I will describe how the study was done.

How Was The Study Done?

clinical studyFor the dietary intake portion of the study, the authors used dietary intake data previously collected from the Environmental Influences on Child Health Outcomes (ECHO) study.

The ECHO study is a consortium of 69 medical centers across multiple states. It is an observational study of mothers and their offspring designed to understand the effects of early life exposures on child health and development.

The current study analyzed dietary intake data for 2450 participants from 6 medical centers across 5 states in the ECHO study. The women in this study were diverse with respect to ethnicity, education, and weight.

All pregnant women in the current study completed at least one 24-hour dietary recall between 6-week gestation until delivery (24% completed one dietary recall. 76% completed two or more dietary recalls). Dietary intake was generally assessed with an expert interviewer and included all foods and beverages consumed in the previous 24 hours.

For the supplement portion of the study, the authors used the NIH Dietary Supplement Label Database because it is the most complete listing of supplements in the US. The authors selected 20,547 supplements that contained at least one of the 6 essential nutrients from this database.

To determine which of the 20,547 supplements contained appropriate levels of the 6 nutrients (vitamin A, vitamin D, folic acid, calcium, iron, and omega-3 fatty acids) selected for this study, the authors used the process described in the introduction above. Briefly:

  • The authors added the amount of each nutrient provided by the supplements in their study to the amount of that nutrient in the diet of American women and:
  • Calculated the minimum amount of each nutrient that would be needed to assure that 90% of American women taking a particular supplement would meet the recommended intake for pregnant and lactating women.
  • Calculated the maximum amount of each nutrient provided by supplements in their study to assure that that 90% of American women taking that supplement would not get potentially toxic amounts of that nutrient.

In other words, for each of the 6 nutrients they calculated a supplemental dose range that was neither too low nor too high. They called this the “appropriate dose range” for each nutrient.

Why Are The 6 Nutrients Included In This Study Important?

Dietary Intake Is Often Inadequate

The diet analysis of pregnant American women in this study found:

  • 42% were at risk of inadequate vitamin A intake.
  • 96% were at risk of inadequate vitamin D intake.
  • 45% were at risk of inadequate folic acid intake.
  • 55% were at risk of inadequate calcium intake.
  • 93% were at risk of inadequate iron intake.
  • 67% were at risk of inadequate omega-3 intake.

The percentage of women at risk for inadequate intake of these nutrients varied with age, ethnicity, and income levels. But the overall message is clear. Most American women are not getting enough of these essential nutrients from their diet alone.

The Risk of Inadequate and Excessive Intake Of These Nutrients

These 6 nutrients were chosen in part because reviews by the Cochrane Collaboration have concluded that inadequate intake of these nutrients are associated with complications during pregnancy and delivery. They can also adversely affect the health and normal development of the baby.

This is important because the Cochrane Collaboration is considered the Gold Standard of clinical studies. You can find a more detailed description of Cochrane Collaboration studies and why they are the Gold standard here.

[Note: The Cochrane Collaboration has not yet evaluated choline, iodine, and vitamin K for pregnant women, but their inclusion in prenatal supplements is supported by multiple clinical studies.]

In addition, excess intake of all these nutrients except omega-3s can harm both the fetus and the mother. The is why the Food and Nutrition Board has set ULs (Upper Limits – the level above which toxicity can occur) for 5 of the 6 nutrients. This is important because previous studies have suggested that up to 25% of women may be getting toxic levels of one or more of these nutrients when you consider both their dietary intake and their prenatal supplement.

Summary

In other words, both too little and too much of these nutrients can harm the mom and her baby. It is critical that prenatal supplements get the dosing right.

It is for that reason that the authors of this study have set an “appropriate dose range” (high enough that 90% of women have enough of each nutrient to prevent deficiency and low enough that 90% of women do not exceed the UL for each nutrient) as the standard for evaluating the adequacy and safety of supplements for pregnant women.

Prenatal Supplements Strike Out Again

Of the 20,547 supplements (421 labeled as prenatal supplements) available on the US market as of December 31, 2022, the investigators reported that:

  • Only 69 (0.3%) supplements contained all 6 nutrients considered essential for a healthy pregnancy.
  • Only 1 supplement contained all 6 nutrients at the appropriate doses, and it wasn’t even labeled as a prenatal supplement.

In addition:

  • One supplement containing all 6 nutrients put 100% of the women in their study at risk for excessive intake of folic acid.
  • Another supplement containing all 6 nutrients put 46% of the women in their study at risk of inadequate calcium intake.

The authors concluded, “Almost no US dietary supplements provide key nutrients in the doses needed for pregnant women. Affordable and convenient products that fill the gap between food-based intake and estimated requirements of pregnancy without inducing excess intake are needed to support pregnant women and their offspring.”

In short, the conclusion of this study can be summed up as, “Prenatal Supplements Strike Out Again”.

[Note: It sometime takes a while for supplement labels to be posted in the NIH Dietary Supplement Label Database. The authors acknowledged that this study may not include supplements introduced or reformulated in the last quarter of 2022.]

Is It Three Strikes And You Are Out? 

pregnant women taking vitaminsIf you are pregnant or thinking of becoming pregnant, this should be a wake-up call.

70% of pregnant women in this country take prenatal supplements, usually based on recommendations by their health care provider. They assume the prenatal supplements meet their needs and the needs of their unborn baby.

Yet three studies evaluating the adequacy of prenatal supplements have been published in the past few months. They took very different approaches in evaluating the supplements. But all three studies concluded that the vast majority of prenatal supplements on the market are woefully inadequate.

You may be wondering, “Is it three strikes, and you are out?” Are there no decent prenatal supplements on the market?  The answer to those questions is, “No. There are good prenatal supplements on the market.”

You may be wondering how I can say that in the face of such overwhelming negative data. That’s because while all 3 studies were very good studies, they each had “blind spots”:

1) Each of the studies used very stringent criteria for identifying adequate prenatal supplements. In some cases, their criteria were stricter than the RDA recommendations and the recommendations of the American College of Obstetrics and Gynecology for pregnant and lactating women. It could be argued that their criteria were too stringent.

2) In the case of the current study, it could also be argued that evaluating only 6 nutrients is not a good criterion for evaluating the adequacy of prenatal supplements. For example, I looked up the one supplement rated as adequate in this study. It does provide appropriate doses of the 6 nutrients this study focused on. It also provides appropriate doses of vitamin K and iodine. But it does not provide choline. It is a very good supplement for women, but it is not the perfect prenatal supplement.

So, what can you do? How can you find the best prenatal supplement for you? Unfortunately, you cannot rely on advice from your friends or your health professional. You cannot rely on advertisements. That is a good place to start, but you have to do your own sleuthing.

With that in mind, I have listed 7 simple rules for selecting the best possible prenatal supplement in  my article about the first two studies. Use these rules for evaluating every prenatal supplement you come across. Happy sleuthing.

The Bottom Line 

A recent study evaluated all 20,547 supplements on the US market to see if they met the needs of pregnant women in this country.

  • They focused on 6 nutrients (vitamin A, vitamin D, folic acid, calcium, iron, and omega-3s) known to be essential for a healthy pregnancy.
  • They determined the dietary intake for all 6 nutrients in a cross section of pregnant women in the US.
  • They added the amount of the 6 nutrients in each of the 20,547 supplements to the dietary intake of those nutrients by pregnant women.
  • They then asked which supplements provided the “appropriate dose” of all 6 nutrients. They defined “appropriate dose” as the dose range that was.
    • High enough to prevent deficiency of that nutrient in 90% of pregnant women taking the supplement…and…
    • Low enough to prevent toxicity from that nutrient in 90% of pregnant women taking the supplement.
  • In other words, for each of the 6 nutrients they calculated a supplemental dose range that was neither too low nor too high.

Of the 20,547 supplements (421 labeled as prenatal supplements) available on the US market:

  • Only 69 (0.3%) supplements contained all 6 nutrients they considered essential for a healthy pregnancy.
  • Only 1 supplement contained all 6 nutrients at the appropriate doses, and it wasn’t even labeled as a prenatal supplement.

The authors concluded, “Almost no US dietary supplements provide key nutrients in the doses needed for pregnant women. Affordable and convenient products that fill the gap between food-based intake and estimated requirements of pregnancy without inducing excess intake are needed to support pregnant women and their offspring.”

[Note: It sometime takes a while for supplement labels to be posted in the NIH Dietary Supplement Label Database. The authors acknowledged that this study may not include supplements introduced or reformulated in the last quarter of 2022 or early 2023.]

If you are pregnant or thinking of becoming pregnant, this should be a wake-up call.

70% of pregnant women in this country take prenatal supplements, usually based on recommendations by their health care provider. They assume the prenatal supplements meet their needs and the needs of their unborn baby.

Yet three studies evaluating the adequacy of prenatal supplements have been published in the past few months. And all three studies concluded that the vast majority of prenatal supplements on the market are woefully inadequate.

You may be wondering, “Is it three strikes, and you are out?” Are there no decent prenatal supplements on the market?  The answer to those questions is, “No. There are good prenatal supplements on the market.”

You may be wondering how I can say that in the face of such overwhelming negative data. That’s because while all 3 studies were very good studies, they each had “blind spots”:

For more details on this study and 7 tips on finding the best prenatal supplement 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. 

____________________________________________________________________________

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

 

 

Is Your Prenatal Supplement Adequate?

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What Should You Look For In A Prenatal Supplement?

Author: Dr. Stephen Chaney

pregnant women taking omega-3You want to do the best for your unborn child. So, you try to find the best prenatal supplement. You may ask your doctor to recommend a prenatal supplement. You may ask your best friend what supplement she used when she was pregnant. Or perhaps you scan online reviews of prenatal supplements by random dietitians or nutrition gurus to select the “best” prenatal supplements.

Then you read the supplement label or the company’s website and see claims like:

  • “Supports optimal nutrition before, during, and after pregnancy”
  • “Packed with 16 nutrients to support fetal development, immunity, energy metabolism, and more”
  • “Concise prenatal formula supports both bone and brain development”

It sounds so good. You think you have found the perfect prenatal supplement. “Right?”

Perhaps not. A recent study (JB Adams et al, Maternal Health, Neonatology, and Perinatology, 8:4, 2022) did an in-depth review of prenatal supplement recommendations and how well prenatal supplements on the market met those recommendations.

The results were not encouraging. The authors concluded, “[Our] analysis found that prenatal supplements vary widely in content, often only contain a subset of essential vitamins, and the levels were often below…recommendations.”

In other words, their study found that most prenatal vitamins may not be adequate to support your needs and the needs of your child through pregnancy and breastfeeding.

I know this is likely to be a topic of great concern for many of you. So, I will examine the study in detail and give you some guidelines for selecting the perfect prenatal supplement.

How Was This Study Done?

clinical studyThis study can be divided into two parts.

#1: What Should The Ideal Prenatal Supplement Contain:

The authors started off by reevaluating the optimal recommendations for prenatal supplements. They reviewed over 200 articles, focusing on articles that:

  • Provided insight into optimal dosage [of essential nutrients] such as treatment studies on the effects of different doses on outcomes and biomarkers.
  • Were larger, more rigorously designed, such as randomized double-blind placebo-controlled studies.

The studies included in their review fell into three categories:

  1. The association of low levels of vitamins with health problems [during pregnancy and in the child after birth].

2) Studies on the changes in [blood] vitamin levels during pregnancy [when the mother is either] un-supplemented or supplemented (The blood level of many vitamins decreases dramatically during pregnancy without supplementation).

3) Clinical trials on the effect of vitamin supplementation on health problems [during pregnancy].

They used these data to create their recommendations for what an ideal prenatal supplement should contain. In some cases, their recommendations were higher than current RDA recommendations for pregnant women.

#2: How Do Currently Available Prenatal Supplements Compare With Their Recommendations For The Ideal Supplement?

For this part of the study, they created a comprehensive list of the nutrients provided by 188 prenatal supplements currently on the market using databases created by the National Institutes of Health. Where these databases were outdated, the nutrient list for that supplement was updated using information on the manufacturer’s websites or labels on retail websites such as Amazon.

Finally, they compared the nutrient content of all 188 prenatal supplements with their recommendations for the ideal prenatal supplement.

Is Your Prenatal Supplement Adequate?

Questioning WomanThere are four points I wish to make before I review the results of this study.

  1. I suspect you are most interested in finding out how prenatal supplements on the market compare with their recommendations for an ideal supplement, so that is what I will discuss below.

2) As I mentioned above, some of their recommendations exceed the current Daily Value (DV) recommendations for pregnant and lactating women. I will point that out whenever it significantly affects the comparisons.

3) The authors of this article made the point that most women going on a prenatal supplement will probably discontinue taking their multivitamin supplement. Thus, their recommendations included nutrients commonly included in multivitamin supplements. This is a valid point, and something you should consider when choosing a prenatal supplement. However, in my discussion below I will focus on the nutrients that are universally recognized as important for pregnancy and lactation.

4) The authors focused on prenatal supplements that had less than the recommended amount of essential nutrients. They did not ask how many of those supplements had excessive amounts of certain nutrients. In my non-systematic review of prenatal supplements, I found several that had doses of some nutrients in thousands of percent of the DV recommendations. In my opinion, this is potentially unsafe for pregnancy and nursing. I will cover this topic in more detail in my discussion.

With that in mind, here are the results of their review.

Vitamins:

When you look at vitamins that have long been recognized as essential for pregnant women, the results are encouraging:

  • Vitamin D, folate, vitamin B12, and vitamin B6 are found in adequate amounts compared to the DV in most prenatal supplements.

However, when you look at nutrients that have more recently been recognized as essential for pregnant women, the story is very different:

  • For vitamin K only 31% of prenatal supplements contain vitamin K and only 16% meet or exceed their recommendation for vitamin K.
    • Their recommendation (90 mcg/day) is identical to the DV for vitamin K. So, there is no doubt that most prenatal supplements do not provide adequate amounts of vitamin K.
  • For choline only 40 % of prenatal supplements contain choline and only 2% meet or exceed their recommendation for choline.
    • Their recommendation (350 mg/day) for choline is less than the 450 mg/day recommended by the NIH and the American College of Obstetricians and Gynecologists.
    • The average prenatal supplement only provides 25 mg of choline, which is wildly inadequate by any standard.
  • For DHA only 42% of prenatal supplements contain DHA and only 1% meet or exceed their recommendation for DHA.
    • Their recommendation (600 mg/day) for DHA is higher than the 200 – 300 mg/day recommended by the most health organizations.
    • However, the average prenatal supplement only provides 94 mg of DHA, so even at 200 – 300 mg/day a substantial percentage of prenatal supplements do not provide adequate amounts of DHA.

Minerals:

calcium supplementsThis study did not consider minerals, so I will draw on another source to estimate the adequacy of minerals in prenatal supplements.

Three key minerals for a healthy pregnancy are iron, calcium, and iodine (Yes, I realize that iodine is not a mineral, but it is usually listed with the minerals on supplement labels. And it is also essential for a healthy pregnancy). Fortunately, another recent study (LG Saldanha et al, Journal of the American Academy of Dietetics, 117: 1429-1436, 2017) looked at the adequacy of these nutrients in 214 prenatal supplements. This study found:

  • The iron DV for pregnant and lactating women is 27 mg/day and 95% of prenatal supplements contained iron at the recommended level.
  • The calcium DV for pregnant and lactating women is 1,300 mg/day. A high percentage (91%) of prenatal supplements contain calcium, but many prenatal supplements only provide 100-200 mg of calcium. That is far less than the DV.
  • The situation for iodine is even more alarming. Only 50% of prenatal supplements contain iodine. And for those that do contain iodine, the average iodine content is only 150 mcg (The DV for pregnant and lactating women is 290 mcg/day).

It is no wonder the authors of these two studies concluded that most prenatal supplements on the market do not provide adequate amounts of all the nutrients needed for a healthy pregnancy. The shortfalls are particularly acute for vitamin K, choline, DHA, iodine, and calcium.

What Should You Look For In A Prenatal Supplement?

Questioning WomanBy now you are probably wondering how you know a good prenatal supplement from a bad one. Here are six simple rules for choosing the ideal prenatal supplement.

  1. Don’t rely on health “gurus” to choose your prenatal supplement for you. I did a little “sleuthing” for you. I searched the internet for websites claiming to have identified the “best” prenatal supplements. I checked out the supplements they recommended, and here is what I found:
  • The supplements the gurus recommended checked all the boxes in that they had some of all the nutrients required for a healthy pregnancy.
  • However, the amount of those nutrients ranged from lows of 10-20% of the DV for pregnant and lactating women to thousands of percent of the DV for others.
  • In other words, they contained grossly inadequate levels of some nutrients and potentially toxic levels of others.

2) Don’t believe label claims or claims made on the manufacturer’s website. Remember the claim, “Concise prenatal formula supports both bone and brain development”, that I mentioned at the beginning of this article? The supplement associated with that claim had only 100 mg of calcium and no DHA. It is hard to imagine a supplement like that supporting either bone or brain health. The claim was bogus.

3) Don’t assume your doctor’s recommendation is the ideal prenatal supplement. A recent study (LG Saldanha et al, Journal of the American Academy of Dietetics, 117: 1429-1436, 2017) compared prescription (the kind your doctor is likely to prescribe) and non-prescription prenatal supplements. It found:

  • Compared with non-prescription supplements, prescription supplements contained significantly fewer vitamins (9 versus 11) and minerals (4 versus 8).
  • While prescription supplements contained more folic acid than non-prescription supplements, they contained significantly less vitamin A, vitamin D, iodine, and calcium.

4) Look for a prenatal supplement containing all the essential nutrients, not just those important for a healthy pregnancy. The authors of the first study made the point that most women will stop taking their regular multivitamin when they start their prenatal supplement. If that is you, your prenatal supplement should contain the nutrients you were getting from your multivitamin.

5) Look for a prenatal supplement that provide 100% of DV for all nutrients except the bulky ones. The ideal prenatal supplement should contain 100% of the DV for pregnant and lactating women for all essential nutrients. Avoid supplements with very low amounts of some nutrients and large excesses of others.

  • Bulky nutrients like calcium, magnesium, and choline are exceptions. It would be hard to get 100% DV for those nutrients in any supplement you could swallow.

6) Look for a prenatal supplement that “fills the gap” for bulky nutrients.

  • Fortunately, the NIH has estimated how much of these nutrients the average American woman gets in her diet. That allows us to estimate how much the average woman needs to get from her prenatal supplement to bring her total intake up to the DV for pregnant and lactating women. That amounts to 458 mg for calcium, 166 mg for magnesium, and 272 mg for choline.
    • That gives you a reasonable benchmark for assessing whether a prenatal supplement is providing enough of those important nutrients. When you read their labels, you will find most prenatal supplements are woefully inadequate for these nutrients.
    • You also need to ask whether your diet is “average”. For example, the average American gets 72% of their calcium from dairy foods. If you do not consume dairy, you may need to get more calcium from your supplement.

7) Avoid the excesses. Your unborn baby is precious. You don’t want to expose it to potentially toxic doses of vitamins or minerals. Avoid any prenatal supplement containing thousands of percent of the DV for some nutrients. And I would recommend caution with supplements containing over 200% of the DV for some nutrients if you are taking other supplements that may provide the same nutrient(s).

The Bottom Line 

Two recent studies have surveyed hundreds of prenatal vitamins and asked whether they provided adequate amounts of the nutrients that are essential for a healthy pregnancy. The results were shocking.

  • While most prenatal supplements provided adequate amounts of folic acid, vitamin B12, vitamin B6, vitamin D, and iron…
  • They were woefully inadequate for vitamin K, calcium, choline, iodine, and DHA – all nutrients that are essential for a healthy pregnancy.
  • Furthermore, prescription prenatal supplements (the kind your doctor is likely to prescribe) were no better than non-prescription supplements.

The authors of the first study concluded, “[Our] analysis found that prenatal supplements vary widely in content, often only contain a subset of essential vitamins, and the levels were often below…recommendations.”

In other words, their study found that most prenatal vitamins on the market may not be adequate to support your needs and the needs of your child through pregnancy and breastfeeding.

For more details on this study and my discussion of how you can select the ideal prenatal supplement for you and your unborn child, 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

 

Do Calcium Supplements Increase Deaths From Heart Valve Disease?

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What Did This Study Get Wrong?

Author: Dr. Stephen Chaney

Aortic Stenosis“Killer calcium” is back. Once again, we are seeing headlines saying that calcium supplementation increases our risk of dying from heart disease. If you have seen these headlines, you are probably confused.

After all, there have been three major clinical studies looking at the effect of calcium supplementation on heart disease risk. These studies followed close to 100,000 Americans for 10-20 years. And none of the studies found any increase in the risk of developing or dying from heart disease for people taking calcium supplements. For more information on this topic, see an article from “Health Tips From the Professor”.

You are probably wondering, “What is going on? I thought this issue was settled”.

In the first place, this study did not look at heart disease in general, but on a very specific form of heart valve disease called aortic stenosis. Aortic stenosis is a narrowing of the heart valve leading to the aorta. And it is often associated with calcification of the heart valve.

The cause of aortic stenosis is complex, but it is associated with:

  • Chronic inflammation.
  • High cholesterol levels.
  • Tobacco use.
  • Dysregulation of calcium metabolism caused by things like elevated parathyroid levels and end-stage kidney disease.
  • Elevated blood levels of calcium and/or vitamin D.

Because of the role of calcium and vitamin D in aortic stenosis, the current study (N Kassis et al, Heart, Epub ahead of print, 1-9, 2022) was designed to ask whether calcium and vitamin D supplementation influenced the risk of dying from aortic stenosis.

How Was This Study Done?

Heart Disease StudyThe Cleveland Clinic scanned their Echocardiography Database for patients aged 60 years or more who had been diagnosed with mild to moderate aortic stenosis. 2,657 patients met these criteria (average age = 74, 58% men) and were followed for an average of 59 months in their database.

In terms of calcium and vitamin D supplementation:

  • 49% did not supplement.
  • 12.5% supplemented with vitamin D (dose not defined).
  • 38.5% supplemented with calcium (500 – 2,000 mg/day) ± vitamin D.

The study looked at the correlation between vitamin D supplementation and calcium supplementation with:

  • Aortic valve replacement surgery.
  • All-cause mortality* with and without aortic valve replacement surgery.
  • Cardiovascular mortality* with and without aortic valve replacement surgery.

*Note: Since all the patients had aortic stenosis at the beginning of the study, both all-cause and cardiovascular mortality were primarily due to aortic stenosis.

Do Calcium Supplements Increase Deaths From Heart Valve Disease?

Before I describe the results of the study, there are two things you need to know:

  • Vitamin D supplementation did not have a significant effect on any outcome studied, so I will not mention vitamin D in the rest of this article.
  • In the calcium supplementing group, there were only a few people taking calcium supplements without vitamin D. However, their outcomes were the same as for people taking calcium + vitamin D supplements. Therefore, the authors discussed their results in terms of calcium supplementation, not calcium + vitamin D supplementation. I will do the same.

With those two things in mind, here is what the study found.

With respect to the need for aortic valve replacement surgery:

  • Calcium supplementation increased the need for surgery by 50%.

With respect to all-cause mortality:

  • Calcium supplementation increased the risk of death by 31%. When you divided the results into patients who did and did not have aortic valve replacement surgery within the 59-month follow-up of this study:
    • Those who received aortic valve replacement surgery did not have a statistically significant increase in risk of death.
    • Those who did not receive aortic valve replacement surgery had a 38% increased risk of death.

With respect to cardiovascular mortality:

  • Calcium supplementation doubled the risk of death. When you divided the results into patients who did and did not have aortic valve replacement surgery within the 59-month follow-up of this study:
    • Those who received aortic valve replacement surgery did not have a statistically significant increase in risk of death.
    • Those who did not receive aortic valve replacement surgery had a 205% increased risk of death.

The authors concluded, “Supplemental calcium … is associated with lower survival and greater AVR [aortic valve replacement surgery] in elderly patients with mild to moderate AV [aortic stenosis].”

What Did This Study Get Wrong?

thumbs down symbolLet me start by looking at the limitations of this study.

#1: This is a single study. It is a well-designed study, but it is only one study. And, as the authors acknowledge, previous studies have come down on both sides of this issue. Until we have more well-designed studies that come to the same conclusion, we cannot be confident this study is correct.

#2: The results of this study could have been significantly influenced by confounding variables.

For example:

  • End-stage kidney disease is associated with a dysregulation of calcium metabolism that can lead to aortic valve calcification. Patients in the calcium supplementation group had a 2-fold higher incidence of chronic kidney disease and a 10-fold higher incidence of kidney dialysis.
  • There were also significant differences in several diseases and drugs that influence the risk of developing aortic stenosis between the groups.

In the words of the authors, “Given the degree of clinical differences between the groups, there was a risk of residual confounding that may have impacted our findings; we attempted to mitigate this with our statistical model.”

However, as Mark Twain is quoted as saying, “There are lies. There are damn lies. And then there are statistics.”

That is a humorous way of saying we should not put too much faith in statistical manipulations of the data.

#3: They did not measure parathyroid levels. That is a serious omission because elevated parathyroid levels are a major driver of the type of dysfunctional calcium metabolism that could lead to calcification of the aortic valve.

#4: Serum calcium and vitamin D levels were slightly lower in the calcium supplementation group. This is unexpected because aortic stenosis is usually associated with higher serum calcium and vitamin D levels.

The authors speculated this might be due to transient increases in serum calcium levels following supplementation. This is possible for some calcium supplements, but not others.

Specifically, some calcium supplements are marketed on how quickly they get into the bloodstream. But those same supplements often do not provide all the nutrients needed for bone formation. There is always the possibility that excess calcium not used for bone formation might be deposited where we do not want it (such as in the aortic valve).

What Did This Study Get Right?

thumbs up#1: It was a larger, longer lasting study than previous studies on the effect of calcium supplementation on aortic stenosis. Even though it has limitations, we shouldn’t discount it. It might just be correct.

#2: It doesn’t necessarily conflict with the earlier studies showing that calcium supplementation doesn’t increase cardiovascular disease risk. That’s because the design of these studies is very different.

  • The health of the people studied was very different.
    • The earlier studies started with healthy adults and asked whether calcium supplementation increased their risk of developing cardiovascular disease.
    • This study started with people who already had a form of cardiovascular disease associated with abnormal calcium metabolism and asked whether calcium supplementation increased their risk of dying from the disease.
  • The age of the people studied was very different.
    • The earlier studies started with middle-aged adults and followed them for 10-20 years
    • This study started with people in their mid-70’s and followed them for almost 6 years.
  • The type of cardiovascular disease studied was different.
    • The earlier studies included all types of cardiovascular disease.
    • This study focused on a very minor type of cardiovascular disease, aortic stenosis. Aortic stenosis accounts for about 10% of all cardiovascular disease 17% of cardiovascular deaths. There may not have been enough deaths from aortic stenosis in the previous studies to have had a statistically significant effect on the results.

Given all these differences, the results of this study may not be incompatible with the results of previous studies

What Does This Study Mean For You?

There are three important takeaways from this and previous studies:

1) For most Americans calcium supplementation does not increase the risk of cardiovascular disease. That has been shown in three major clinical studies.

2) However, if you have been diagnosed with aortic stenosis, calcium supplementation may increase your risk of needing heart valve replacement or of dying from the disease. This study is not definitive, but I would advise caution.

You may wish to discuss with your doctor how to best balance:

    • The need for calcium supplementation to prevent osteoporosis…
    • With the need to limit calcium supplementation to prevent adverse outcomes from your aortic stenosis.

3) Finally, the authors did not discuss a very significant observation from this study, namely that heart valve replacement reduced the risk of dying from aortic stenosis in people taking calcium supplements.

Aortic valve replacement is the only proven treatment for aortic stenosis. If your doctor recommends aortic valve replacement, you should consider it.

The Bottom Line

A recent study looked at the effect of calcium supplementation for people with aortic stenosis, a rare form of heart disease.

The study found:

  • Calcium supplementation increased the need for aortic valve replacement surgery by 50%.
  • Calcium supplementation increased the risk of all-cause mortality* by 31%. When you divided the results into patients who did and did not have aortic valve replacement surgery during the study:
    • Those who received aortic valve replacement surgery did not have a statistically significant increase in risk of death.
  • Calcium supplementation doubled the risk of cardiovascular mortality*. When you divided the results into patients who did and did not have aortic valve replacement surgery within the 59-month follow-up of this study:
    • Those who received aortic valve replacement surgery did not have a statistically significant increase in risk of death.

*Note: Since all the patients enrolled in this study had aortic stenosis at the beginning of the study, these deaths were primarily due to aortic stenosis.

The authors concluded, “Supplemental calcium … is associated with lower survival and greater AVR [aortic valve replacement surgery] in elderly patients with mild to moderate AV [aortic stenosis].”

There are three important takeaways from this and previous studies:

1) For most Americans calcium supplementation does not increase the risk of cardiovascular disease. That has been shown in three major clinical studies.

2) However, if you have been diagnosed with aortic stenosis, calcium supplementation may increase your risk of needing heart valve replacement or of dying from the disease. This study is not definitive, but I would advise caution.

  • You may wish to discuss with your doctor how to best balance:
    • The need for calcium supplementation to prevent osteoporosis…
    • With the need to limit calcium supplementation to prevent adverse outcomes from your aortic stenosis.

3) Finally, the authors did not discuss a very significant observation from this study, namely that heart valve replacement reduced the risk of dying from aortic stenosis in people taking calcium supplements.

Aortic valve replacement is the only proven treatment for aortic stenosis. If your doctor recommends aortic valve replacement, you should consider it.

For more details, 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.

Can Vegans Have Strong Bones?

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When Is Supplementation Important? 

Author: Dr. Stephen Chaney

Healthy BoneWhole food, vegan diets are incredibly healthy.

  • They have a low caloric density, which can help you maintain a healthy weight.
  • They are anti-inflammatory, which can help prevent all the “itis” diseases.
  • They are associated with reduced risk of diabetes, heart disease, and some cancers.
  • Plus a recent study has shown that vegans age 60 and older require 58% fewer medications than people consuming non-vegetarian diets.

But vegan diets are incomplete, and as I have said previously, “We have 5 food groups for a reason”. Vegan diets tend to be low in several important nutrients, but for the purposes of this article I will focus on calcium and vitamin D. Vitamin D is a particular problem for vegans because mushrooms are the only plant food that naturally contain vitamin D, and the vitamin D found in mushrooms is in the less potent D2 form.

Calcium and vitamin D are essential for strong bones, so it is not surprising that vegans tend to have less dense bones than non-vegans. But are these differences significant? Are vegans more likely to have broken bones than non-vegans?

That is the question the current study (DL Thorpe et al, American Journal of Clinical Nutrition, 114: 488-495, 2021) was designed to answer. The study also asked whether supplementation with calcium and vitamin D was sufficient to reduce the risk of bone fracture in vegans.

How Was This Study Done?

Clinical StudyThe data for this study were obtained from the Adventist Health Study-2. This is a study of ~96,000 members of the Seventh-day Adventist Church in North America who were recruited into the study between 2002 and 2007 and followed for up to 15 years.

Seventh-day Adventists are a good group for this kind of study because the Adventist church advocates a vegan diet consisting of legumes, whole grains, nuts, fruits, and vegetables. However, it allows personal choice, so a significant number of Adventists choose modifications of the vegan diet and 42% of them eat a nonvegetarian diet.

This diversity allows studies of the Adventist population to not only compare a vegan diet to a nonvegetarian diet, but also to compare it with the various forms of vegetarian diets.

This study was designed to determine whether vegans had a higher risk of hip fractures than non-vegan Adventists. It was performed with a sub-population of the original study group who were over 45 years old at the time of enrollment and who were white, non-Hispanic. The decision to focus on the white non-Hispanic group was made because this is the group with the highest risk of hip fractures after age 45.

At enrollment into the study all participants completed a comprehensive lifestyle questionnaire which included a detail food frequency questionnaire. Based on the food frequency questionnaire participants were divided into 5 dietary patterns.

  • Vegans (consume only a plant-based diet).
  • Lacto-ovo-vegetarian (include dairy and eggs in their diet).
  • Pesco-vegetarians (include fish as well as dairy and eggs in their diet).
  • Semi-vegetarians (include fish and some non-fish meat (primarily poultry) as well as dairy and eggs in their diet).
  • Non-vegetarians (include all meats, dairy, and eggs in their diet). Their diet included 58% plant protein, which is much higher than the typical American diet, but much less than the 96% plant protein consumed by vegans.

Every two years the participants were mailed follow-up questionnaires that included the question, “Have you had any fractures (broken bones) of the wrist or hip after 2001? Include only those that came from a fall or minor accident.”

Can Vegans Have Strong Bones?

Unhealthy BoneThe results of this study were striking.

  • When men and women were considered together there was an increasing risk of hip fracture with increasing plant-based diet patterns. But the differences were not statistically significant.
  • However, the effect of diet pattern on the risk of hip fractures was strongly influenced by gender.
    • For men there was no association between diet pattern and risk of hip fractures.
    • For women there was an increased risk of hip fractures across the diet continuum from nonvegetarians to vegans, with vegan women having a 55% higher risk of hip fracture than nonvegetarian women.
  • The increased risk of hip fractures in vegan women did not appear to be due to other lifestyle differences between vegan women and nonvegetarian women. For example:
    • Vegan women were almost twice as likely to walk more than 5 miles/week than nonvegetarian women.
    • Vegan women consumed more vitamin C and magnesium, which are also important for strong bones, than nonvegetarian women.
    • Vegan women got the same amount of daily sun exposure as nonvegetarian women.
  • The effect of diet pattern on the risk of hip fractures was also strongly influenced by supplementation with Calcium Supplementcalcium and vitamin D.
    • Vegan women who did not supplement with calcium and vitamin D had a 3-fold higher risk of hip fracture than nonvegetarian women who did not supplement.
    • Vegan women who supplemented with calcium and vitamin D (660 mg/day of calcium and 13.5 mcg/day of vitamin D on average) had no increased risk of hip fracture compared to nonvegetarian women who supplemented with calcium and vitamin D.
  • In interpreting this study there are a few things we should note.
    • The authors attributed the lack of an effect of a vegan diet on hip fracture risk in men to anatomical and hormonal differences that result in higher bone density for males.
    • In addition, because the average age of onset of osteoporosis is 15 years later for men than for women, this study may not have been adequately designed to measure the effect of a vegan diet on hip fracture in men. Ideally, the study should have enrolled participants who were at least 60 or older if it wished to detect an effect of diet on hip fractures in men.
    • Finally, because the study enrolled only white, non-Hispanic women into the study, it does not tell us the effect of a vegan diet on women of other ethnicities. Once again, if there is an effect, it would likely occur at an older age than for white, non-Hispanic women.

The authors concluded, “Without combined supplementation of both vitamin D and calcium, female vegans are at high risk of hip fracture. However, with supplementation the excessive risk associated with vegans disappeared.”

Simply put, vegan diets are very healthy. They reduce the risk of heart disease, high blood pressure, diabetes, some cancers, and inflammatory diseases.

However, the bad news is:

  • Vegan women have a lower intake of both calcium and vitamin D than nonvegetarian women.
  • Vegan women have lower bone density than nonvegetarian women.
  • Vegan women have a higher risk of hip fracture than nonvegetarian women.

The good news is:

  • Supplement with calcium and vitamin D eliminates the increased risk of hip fracture for vegan women compared to nonvegetarian women.

When Is Supplementation Important?

Supplementation PerspectiveMuch of the controversy about supplementation comes from a “one size fits all” mentality. Supplement proponents are constantly proclaiming that everyone needs nutrient “X”. And scientists are constantly proving that everyone doesn’t need nutrient “X”. No wonder you are confused.

I believe in a more holistic approach for determining whether certain supplements are right for you. Dietary insufficiencies, increased need, genetic predisposition, and diseases all affect your need for supplementation, as illustrated in the diagram on your left. I have discussed this approach in more detail in a previous issue (https://www.chaneyhealth.com/healthtips/do-you-need-supplements/) of “Health Tips From the Professor”.

But today I will just focus on dietary insufficiencies.

  • Most Americans consume too much highly processed fast and convenience foods. According to the USDA, we are often getting inadequate amounts of calcium, magnesium, and vitamins A, D, E and C. Iron is also considered a nutrient of concern for young children and pregnant women.
  • According to a recent study, regular use of a multivitamin is sufficient to eliminate most these deficiencies except for calcium, magnesium, and vitamin D. A well-designed calcium, magnesium and vitamin D supplement may be needed to eliminate those deficiencies.
  • In addition, intake of omega-3 fatty acids from foods appears to be inadequate in this country. Recent studies have found that American’s blood levels of omega-3s are among the lowest in the world and only half of the recommended level for reducing the risk of heart disease. Therefore, omega-3 supplementation is often a good idea.

Ironically, “healthy” diets are not much better when it comes to dietary insufficiencies. That is because many of these diets eliminate one or more food groups. And, as I have said previously, we have 5 food groups for a reason.

Take the vegan diet, for example:

  • There is excellent evidence that whole food, vegan diets reduce the risk of heart disease, diabetes, inflammatory diseases, and some cancers. It qualifies as an incredibly healthy diet.
  • However, vegan diets exclude dairy and meats. They are often low in protein, vitamin B12, vitamin D, calcium, iron, zinc, and long chain omega-3 fatty acids. Supplementation with these nutrients is a good idea for people following a vegan diet.
  • The study described above goes one step further. It shows that supplementation with calcium and vitamin D may be essential for reducing the risk of hip fractures in vegan women.

There are other popular diets like Paleo and keto which claim to be healthy even though there are no long-term studies to back up that claim.

  • However, those diets are also incomplete. They exclude fruits, some vegetables, grains, and most plant protein sources.
  • A recent study reported that the Paleo diet increased the risk of calcium, magnesium, iodine, thiamin, riboflavin, folate, and vitamin D deficiency. The keto diet is even more restrictive and is likely to create additional deficiencies.
  • And it is not just nutrient deficiencies that are of concern when you eliminate plant food groups. Plants also provide a variety of phytonutrients that are important for optimal health and fiber that supports the growth of beneficial gut bacteria.

In short, the typical American diet has nutrient insufficiencies. “Healthy” diets that eliminate food groups also create nutrient insufficiencies. Supplementation can fill those gaps.

The Bottom Line

Vegan diets are incredibly healthy, but:

  • They eliminate two food groups – dairy, and meat protein.
  • They have lower calcium and vitamin D intake than nonvegetarians.
  • They also have lower bone density than nonvegetarians.

The study described in this article was designed to determine whether vegans also had a higher risk of bone fractures. It found:

  • Vegan women who don’t supplement have a 3-fold higher risk of hip fracture than nonvegetarian women.
  • The increased risk of hip fractures in vegan women did not appear to be due to other lifestyle differences between vegan women and nonvegetarian women.
  • Supplementation with calcium and vitamin D (660 mg/day of calcium and 13.5 mcg/day of vitamin D on average) eliminated the difference in risk of hip fracture between vegan women and nonvegetarian women.

In the article above I discuss the importance of supplementation in assuring diets are nutritionally complete.

  • In short, the typical American diet has nutrient insufficiencies. “Healthy” diets that eliminate food groups also create nutrient insufficiencies. Supplementation can fill those gaps.

For more details about the study and a discussion of which supplements may be needed to assure nutritionally adequate diets, 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.

Are Vegan Diets Bad For Your Bones?

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The Secrets To A Healthy Vegan Diet

Author: Dr. Stephen Chaney

Frail ElderlyOsteoporosis 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?

Clinical StudyThe 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:

Unhealthy BoneBone 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 FractureBone 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

Emoticon-BadThe 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.

  1. 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.soy

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 Weight Trainingessentials 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.

  1.     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.

Do Calcium And Magnesium Reduce Migraines?

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Avoiding Migraines

Author: Dr. Stephen Chaney

headacheMigraines can be agonizing. They can upend your life. Drugs provide some relief, but they have side effects. I am often asked about natural approaches for preventing migraines.

My simple answer is that there is no single thing that can eliminate migraines. As the saying goes, “It takes a village”. There is no “magic” supplement or herb you can take. It requires a holistic approach to defeat migraines.

I will discuss the holistic approach for migraines in more detail below. But first I would like to describe a recent study (SH Meng et al, Frontiers in Nutrition, doi.org/10.3389/fnut.2021.653765) that suggests calcium and magnesium should be part of that holistic approach.

How Was This Study Done?

Clinical StudyThis study used data from the CDC’s most recent National Health and Nutrition Examination Survey (NHANES). The CDC has been doing these surveys since 1960, but the most recent NHANES study began in 1999.

Briefly, data collection for the current NHANES began in early 1999 and remains a continuous annual survey. Each year approximately 7,000 randomly selected residents across the United States are given the opportunity to participate in the NHANES survey.

The NHANES survey provides information on demographics, physical examinations, laboratory tests, diet surveys, and other health-related questions.

This study used data from 10,798 NHANES participants between 1999 and 2004 who completed a questionnaire asking if they suffered from severe headaches or migraines.

[Based on previous studies they considered self-reported severe headaches as likely migraines and grouped the two together. Accordingly, I will simply refer to them as migraines in this review.]

Here are a few important characteristics of the participants:

  • Gender was 51% male and 49% female.
  • Average age was 51.
  • Average intake was low for both calcium (70% of the RDA) and magnesium (62% of the RDA).
  • Only 20% suffered from migraines. However, the gender discrepancy was significant.
    • Women (64%) were much more likely to suffer from migraines than men (36%). This is consistent with previous studies.

Do Calcium And Magnesium Reduce Migraines?

dairy foodsThe investigators divided intake of both calcium and magnesium into quintiles and compared the frequency of migraines of those in the highest quintile with those in the lowest quintile.

  • For calcium, the highest quintile was ≥1,149 mg/day, and the lowest quintile was ≤378 mg/day.
    • For comparison, the RDA for calcium is 1,200 mg/day for women between 50 and 70 and 1,000 mg/day for men between 50 and 70.
  • For magnesium, the highest quintile was ≥371 mg/day, and the lowest quintile was ≤161 mg/day.
    • For comparison, the RDA for magnesium is 320 mg/day for women over 30 and 420 mg/day for men over 30.

For women:

  • Those with the highest intake of calcium were 28% less likely to suffer from migraines than those with the lowest intake of calcium.
  • Those with the highest intake of magnesium were 38% less likely to suffer from migraines than those with the lowest intake of magnesium.

For men:

  • Those with the highest intake of calcium were 29% less likely to suffer from migraines than those with the lowest intake of calcium.
  • Those with the highest intake of magnesium were 20% less likely to suffer from migraines than those with the lowest intake of magnesium, but this result was not statistically significant.

The authors concluded, “Our study found that high dietary intake of calcium and magnesium…were inversely associated with migraines in women. For men, high dietary calcium intake was inversely associated with migraines. People should pay more attention to dietary calcium and magnesium, which may be an effective way to prevent migraines.”

Avoiding Migraines

headacheThis study showed that RDA levels of both calcium and magnesium are effective at reducing the risk of developing migraines. However, if you suffer from migraines, you are probably looking for more than a 28-38% reduction in migraines. You want them to be gone. That is why a holistic approach is best.

What does a holistic approach for migraines look like? In fact, it is very individualistic. Different things work for different people. Here are a few suggestions.

  • In addition to calcium and magnesium, make sure you are getting enough omega-3 fatty acids, vitamin D, coenzyme Q10, riboflavin, and vitamin B12 in your diet.
  • Avoid “trigger foods”. Different foods trigger migraines in different people, but here are a few of the most common.
    • Nitrate-containing processed meats.
    • Cheeses containing tyramine such as blue, feta, cheddar, Parmesan, and Swiss.
    • Alcohol, especially red wine.
    • Chocolate and foods containing caffeine.
    • Processed foods.
  • Some evidence suggests that a plant-based diet may reduce migraines, but only if it includes adequate amounts of the nutrients listed above.
  • Stay hydrated. Drink pure water rather than other beverages.
  • If overweight, shed some pounds. Obesity is linked to migraines.
  • Get adequate rest.
  • Try stress reduction techniques like yoga or meditation.

This is not a comprehensive list. If you have migraines, I probably left some of your favorite approaches off my list. The bottom line is that there are many natural approaches for reducing migraines. None is a “magic bullet” by itself but keep searching for the ones that help you the most.

What Does This Study Mean For You?

calcium supplementsGetting back to magnesium and calcium, this study shows that RDA levels of both calcium and magnesium are sufficient to significantly reduce your risk of migraines. The problem is that many Americans are not getting RDA levels of calcium and magnesium from their diets. Why is that?

  • Dairy foods are the biggest source of calcium in the American diet. However, many Americans don’t get enough dairy foods in their diet because:
    • Restrictive diets like Vegan and Paleo exclude dairy foods.
    • They are trying to avoid saturated fats.
    • They are lactose intolerant or have milk allergies.
    • They have a malabsorption disease or have undergone gastric bypass surgery.
  • Magnesium is found in lots of whole foods. The problem is that most Americans are eating highly processed foods instead of whole foods.

If you are not getting enough calcium and magnesium in your diet, supplementation is a viable option. However, you don’t want megadoses of either one. You just want to reach RDA levels. Here are some tips:

Calcium:

  • Start by estimating how much calcium you are getting from your diet. My rule of thumb is to estimate 250 mg of calcium from each serving of dairy and an additional 200 mg of calcium from a typical diet. Subtract that from 1,200 mg, and you have the amount of supplemental calcium you need to match the highest quintile of calcium intake in this study.
  • The calcium supplement should also contain vitamin D because vitamin D is needed for calcium absorption.
  • Take no more than 500 mg of supplemental calcium at a time. Higher amounts are absorbed less efficiently.
  • It is generally better to take calcium supplements between meals than with meals. That is because many components of the typical diet interfere with calcium absorption. For example,
    • Phytates in some high fiber foods.
    • Oxalic acid in spinach and some other leafy greens.
    • Saturated fats.

Magnesium:

  • The amount of magnesium in your diet is more difficult to calculate. However, 200 mg of magnesium will take you from the lowest quintile to the highest quintile in this study. And if you are already at the highest quintile, an extra 200 mg will not be excessive.
  • Magnesium can cause diarrhea, so I suggest a slow-release magnesium supplement.

The Bottom Line 

Migraines can be agonizing. They can upend your life. Drugs provide some relief, but they have side effects. I am often asked about natural approaches for preventing migraines.

My simple answer is that there is no single thing that can eliminate migraines. As the saying goes, “It takes a village”. There is no “magic” supplement or herb you can take. It requires a holistic approach to defeat migraines.

A recent study reported that calcium and magnesium should be part of a holistic approach to reduce migraines.

The study found that:

For women:

  • Those with the highest intake of calcium were 28% less likely to suffer from migraines than those with the lowest intake of calcium.
  • Those with the highest intake of magnesium were 38% less likely to suffer from migraines than those with the lowest intake of magnesium.

For men:

  • Those with the highest intake of calcium were 29% less likely to suffer from migraines than those with the lowest intake of calcium.
  • Those with the highest intake of magnesium were 20% less likely to suffer from migraines than those with the lowest intake of magnesium, but this result was not statistically significant.

The authors concluded, “Our study found that high dietary intake of calcium and magnesium…were inversely associated with migraines in women. For men, high dietary calcium intake was inversely associated with migraines. People should pay more attention to dietary calcium and magnesium, which may be an effective way to prevent migraines.”

For more details about other components of a holistic approach and my recommendations for calcium and magnesium 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.

Does Poverty Affect Nutritional Status?

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How Can We Improve Nutrition In Disadvantaged Communities?

Calcium FoodsRecently there has been increased focus on health disparities in disadvantaged communities. In our discussions of the cause of these health disparities, two questions seem to be ignored.

1. Does poverty play a role in poor nutrition?

2. Does poor nutrition play a role in the health disparities we see in disadvantaged communities?

The study (K Marshall et al, PLoS One 15(7):e0235042) I discuss in this week’s “Health Tips From The Professor” attempts to address both of these questions.

Before, I start, let me put this study into context.

  • Osteoporosis is a major health problem in this country. Over 2 million osteoporosis-related fractures occur each year, and they cost our health care system over 19 billion dollars a year. Even worse, for many Americans these osteoporosis-related fractures often cause:
    • A permanent reduction in quality of life.
    • Immobility, which can lead to premature death.
  • Inadequate calcium and vitamin D intakes increase the risk of osteoporosis.

While most studies simply report calcium and vitamin D intakes for the general population, this study breaks them down according to ethnicity and income levels. The results were revealing.

How Was The Study Done?

Clinical StudyThis study drew on data from the 2007-2010 and 2013-2014 National Health and Nutrition Examination Surveys (NHANES). These surveys are conducted by the National Center for Health Statistics, which is part of the CDC. They are designed to assess the health and nutritional status of adults and children in the United States and are used to produce health statistics for the nation.

The NHANES interview includes demographic, socioeconomic, dietary, and health-related questions. The examination component consists of medical, dental, and physiological measurements, as well as laboratory tests administered by highly trained medical personnel. All participants visit a physician. Dietary interviews and body measurements are included for everyone.

This study measured calcium intake, vitamin D intake, and osteoporosis for adults 50 and older. The data were separated by gender, ethnic group and income level. Four different measures of poverty were used. For purposes of simplicity, I will only use one of them, income beneath $20,000, for this article.

Does Poverty Affect Nutritional Status?

The Effect of Ethnicity And Gender On Calcium And Vitamin D Intake: 

FriendsWhen the authors looked at the effect of ethnicity and gender on calcium and vitamin D intake, in people aged 50 and older the results were (Note: I am using the same ethnic nomenclature used in the article):

Hispanics:

    • 66% (75% for women and 56% for men) were getting inadequate calcium intake.
    • 47% (47% for women and 47% for men) were getting inadequate vitamin D intake.

Non-Hispanic Blacks:

    • 75% (83% for women and 64% for men) were getting inadequate calcium intake.
    • 53% (51% for women and 54% for men) were getting inadequate vitamin D intake.

Non-Hispanic Whites:

    • 60% (64% for women and 49% for men) were getting inadequate calcium intake.
    • 33% (30% for women and 37% for men) were getting inadequate vitamin D intake.

For simplicity, we can generalize these data by saying:

Gender:

    • Women are more likely to be calcium-deficient than men.
    • Men are more likely to be vitamin D-deficient than women.

Ethnicity: For both genders and for both calcium and vitamin D:

    • The rank order for deficiency is Non-Hispanic Blacks > Hispanics > Non-Hispanic Whites.

The Effect Of Poverty On Calcium Intake, Vitamin D Intake, And Osteoporosis:

PovertyWhen looking at the effect of poverty, the authors asked to what extent poverty (defined as income below $20,000/year) increased the risk of calcium and vitamin D deficiency in adults over 50. Here is a summary of the data

Hispanics:

    • For both Hispanic women and Hispanic men, poverty had little effect on the risk of calcium and vitamin D deficiency.

Non-Hispanic Blacks:

    • For Non-Hispanic Black women, poverty had little effect on the risk of calcium deficiency, and vitamin D deficiency.
    • For Non-Hispanic Black men, poverty increased the risk of both calcium and vitamin D deficiency by 32%.

Non-Hispanic Whites:

    • For Non-Hispanic White women, poverty had little effect on the risk of calcium deficiency but increased the risk of vitamin D deficiency by 30%.
    • For Non-Hispanic White men, poverty increased the risk of both calcium deficiency and vitamin D deficiency by 18%.

For simplicity, we can generalize these data by saying:

    • Poverty increased the risk of both calcium and vitamin D deficiency for Non-Hispanic Black men, Non-Hispanic White women, and Non-Hispanic White men.

Other statistics of interest:

  • The SNAP program (formerly known as Food Stamps) had little effect on calcium and vitamin D intake. There are probably two reasons for this:
    • In the words of the authors, “While the SNAP program has been shown to decrease levels of food insecurity, the quality of the food consumed by SNAP participants does not meet the standards for a healthy diet.” In other words, the SNAP program ensures that participants have enough to eat, but SNAP participants are just as likely to prefer junk and convenience foods as the rest of the American population. The SNAP program provides no incentive to eat healthy foods.
    • We also need to remember that dairy foods are a major source of calcium and vitamin D in the American diet and that Hispanics and Non-Hispanic Blacks are more likely to be lactose-intolerant than the rest of the American population. There are other sources of calcium and vitamin D in the American diet. But without some nutrition education, most Americans are unaware of what they are.
  • An increased risk of osteoporosis was found in Non-Hispanic Black men, and Non-Hispanic Whites with incomes below $20,000/year.
    • This increased risk of osteoporosis was seen primarily for the individuals in each group who were deficient in calcium and vitamin D. There were other factors involved, but I will focus primarily on the effect of poverty on calcium and vitamin D intake in the discussion below.

How Can We Improve Nutrition In Disadvantaged Communities?

Questioning WomanLet’s start with the two questions I posed at the beginning of this article:

1. Does poverty play a role in poor nutrition?

2. Does poor nutrition play a role in the health disparities we see in disadvantaged communities?

In terms of calcium intake, vitamin D intake, and the risk of osteoporosis, the answer to both questions appears to be, “Yes”. So, the question becomes, “What can we do?”

It is when we start to ask what we can do to increase calcium and vitamin D intake and decreased the risk of osteoporosis in disadvantaged communities that we realize the complexity of the problem. There are no easy answers. Let’s look at some of the possibilities.

[Note: I am focusing on what we can do to prevent osteoporosis, not to detect or treat osteoporosis. The solutions for those issues would be slightly different.]

1. We could increase funding for SNAP. That would increase the quantity of food available for low income families, but, as noted above, would do little to improve the quality of the food eaten.

2. We could improve access to health care in disadvantaged communities. But unless physicians started asking their patients what they eat and start recommending a calcium and vitamin D supplement when appropriate, this would also have little impact on diet quality.

3. We could improve nutrition education. A colleague of mine in the UNC School of Public Health ran a successful program of nutrition education through churches and community centers in disadvantaged communities for many years. The program taught people how to eat healthy on a limited budget. Her program improved the health of many people in disadvantaged communities.

However, the program was funded through grants. When she retired, federal and state money to support the program eventually dried up. The program she started is a model for what we should be doing.

4. The authors suggested food fortification as a solution. In essence, they were suggesting that junk and convenience foods be fortified with calcium and vitamin D. That might help, but I don’t think it is a good idea.

If we want to improve the overall health of disadvantaged communities, we need to find ways to replace junk and convenience foods with healthier foods. Adding a few extra nutrients to unhealthy foods does not make them healthy.

5. The authors also said that a calcium and vitamin D supplement would be a cheap and convenient way to eliminate calcium and vitamin D deficiencies. Unfortunately, supplements are currently not included in the SNAP program. Unless that is changed, even inexpensive supplements are a difficult choice for families below the poverty line.

As I said at the beginning of this section, there are no easy answers. It is easy to identify the problem. It would be easy to throw money at the problem. But finding workable solutions that could make a real difference are hard to identify.

Yes, we should make sure every American has enough to eat. Yes, we should make sure every American has access to health care. But, if we really want to improve the health of our disadvantaged communities, we also need to:

  • Change the focus of our health care system from treatment of disease to prevention of disease.
  • Train doctors to ask their patients what they eat and to instruct their patients how simple changes in diet could dramatically improve their health.
  • Provide basic nutrition education to disadvantaged communities at places where they gather, like churches and community centers. This would cover topics like eating healthy, shopping healthy on a limited budget, and cooking healthy.

We don’t necessarily need another massive federal program. But those of us with the knowledge could each volunteer to share that knowledge in disadvantaged communities.

  • Cover basic supplements, like multivitamins, calcium and vitamin D supplements, and omega-3 supplements in food assistance programs like SNAP.

The Bottom Line

Osteoporosis is a major health problem in this country. Over 2 million osteoporosis-related fractures occur each year, and they cost our health care system over 19 billion dollars a year. Even worse, for many Americans these osteoporosis-related fractures often cause:

  • A permanent reduction in quality of life.
  • Immobility, which can lead to premature death.

We know that inadequate calcium and vitamin D intakes increase the risk of osteoporosis. But most studies simply report calcium and vitamin D intakes for the general population. At the beginning of this article, I posed two questions.

  1.  Does poverty play a role in poor nutrition?

2. Does poor nutrition play a role in the health disparities we see in disadvantaged communities?

A recent study looked at the effect of gender, ethnicity and income levels on calcium intake, vitamin D intake, and the risk of developing osteoporosis. The results of this study shed some light on those two questions.

When looking at the effect of gender and ethnicity on the risk of inadequate calcium and vitamin D intake, the study found:

  • Women are more likely to be calcium-deficient than men.
  • Men are more likely to be vitamin D-deficient than women.
  • For both genders and for both calcium and vitamin D, the rank order for deficiency is Non-Hispanic Blacks > Hispanics > Non-Hispanic Whites. [Note: Note: I am using the same ethnic nomenclature used in the study.]
  • Poverty (defined as incomes below $25,000/year) significantly increased the risk of both calcium and vitamin D deficiency for Non-Hispanic Black men, Non-Hispanic White women, and Non-Hispanic White men.
  • An increased risk of osteoporosis was also found in Non-Hispanic Black men, and Non-Hispanic White men and women with incomes below $20,000/year.
  • This increased risk of osteoporosis was seen primarily for the individuals in each group who were deficient in calcium and vitamin D.

In short, this study suggests that the answer to both questions I posed at the beginning of the article is, “Yes”.

For more information and a discussion of what we could do to correct this health disparity in disadvantaged communities, 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.

Health Tips From The Professor