Bone Building Nutrition  – Calcium and Beyond

                                                                                           By Debbie Edson RPh , HealthyMorning.com

Maintaining bone strength as we enter mid-life and beyond is an important goal, not just for postmenopausal women. Men may experience declining bone strength as they age, although generally later in life than women. Most people know that adequate calcium intake is important for healthy bones. It is not widely understood, however, that bone is a complex living tissue continually undergoing a process of building up and breaking down. Strong bones require a constant supply of a variety of nutrients, not just calcium.

What Is Osteoporosis?

Osteoporosis is a disorder of the skeleton characterized by decreased bone strength and increased susceptibility to fractures. Osteoporosis is a tremendous world wide medical problem. Hip fractures are the most debilitating consequence of osteoporosis. Wrist and vertebrae fractures also occur.  In the U.S. the prevalence of osteoporosis in men and women is estimated to increase from 10 million people in 2002 to 14 million by 2020.1 In the U. S. there are 1.5 million osteoporotic fractures per year, costing $18 billion.2

A Review of Calcium Supplementation

Recommended intake of calcium in people at risk for osteoporosis is 1000 to 1500 mg of elemental calcium per day, in 3 to 4 divided doses. Calcium may be obtained from supplements or food. People greater than 50 years old or with low bone mineral density require ranges at the higher end – 1200mg to 1500 mg daily.

Adequate calcium intake decreases the rate of bone loss in postmenopausal women from 2% per year to 0.25% to 1% per year. Long term calcium supplementation decrease primary fracture rates by 30% to 35%. 3

It is important to note the amount of elemental calcium per tablet or capsule on supplement labels. Calcium is not present by itself; it must be delivered in salt form. Different salts of calcium provide different amounts of elemental calcium per given weight of the salt. The number of tablets or capsules per day you take to get 1000 mg of calcium will vary depending upon the product you choose. Calcium carbonate is 40% calcium. To obtain 500 mg of elemental calcium you need to take 1500 mg of calcium carbonate. Calcium citrate is 21% calcium. Nine hundred and fifty mg of calcium citrate are required to deliver 200 mg of calcium. As an example, to obtain 1000 mg of calcium from calcium carbonate you need to take two tablets of a commonly available product. To obtain 1000 mg of calcium from calcium citrate, a typical product requires 5 tablets per day. Read labels carefully.

Another important consideration in product selection is the degree to which various salt forms are absorbed from the stomach. Calcium carbonate and calcium triphosphate require an acid environment in the stomach to be absorbed. Calcium citrate, lactate and gluconate do not. This difference in absorption characteristics is important for two categories of people – the elderly and those on medications that reduce gastric acidity. The elderly commonly experience age related decrease in stomach acid secretion. Medications that reduce stomach acid, such as those prescribed for ulcers or gastric reflux, raise the pH of the stomach contents. Both situations create an environment unfavorable for absorption of calcium from carbonate and triphosphate salts. For the elderly and those on acid blocking medications, calcium citrate, lactate or gluconate is a better choice.

Calcium carbonate is best taken with meals. Calcium citrate can be taken without regard to meals.

Constipation with calcium supplementation is a problem for some. Changing from calcium carbonate to calcium citrate may help. Taking calcium with magnesium in a 2:1 ratio may also be of benefit. Drinking plenty of water and getting adequate fiber and exercise is also useful. 

Vitamin D

Vitamin D is required for absorption of calcium. Vitamin D deficiency is wide spread, especially in people living in northern climates. According to a scientific review, “inadequate vitamin D intake may be a greater concern that poor calcium intake, as vitamin D may not be as prevalent in the diet as calcium, and patients may be less aware of vitamin D requirements than calcium.”1 Studies have shown that vitamin D, even without calcium supplementation, reduces fracture rates. Vitamin D also contributes to strong muscles, which reduce the risk of falling.

A meta-analysis is a study that re-analyzes data from many previous studies. A meta-analysis on vitamin D looked at the minimum effective dose.4   Taking only 400 units a day had no effect on fracture rates. Doses of at least 700-800 units daily were required to reduce fracture rates; at this level a 26% reduction was observed. Some doctors suggest that daily doses should be significantly higher, in the range of 1000-2000 units per day. Ask you physician about your optimum dose of vitamin D.

Other Nutrients For Bone

In addition to calcium and vitamin D, the following nutrients may contribute to bone health: vitamin K, magnesium, zinc, copper, manganese, boron, strontium, silicon, and vitamins C, B6, B12, and folic acid.3,5

Vitamin K is required for the production of osteocalcin, a protein found in bone that plays a role in mineralization. People with osteoporosis tend to have suboptimal levels of vitamin K. Two forms of vitamin K occur in food: Vitamin K1 and K2. Vitamin K1 is found in green leafy vegetables. Vitamin K2 is found in meat, eggs and fermented cheese.  A particular form of vitamin K2, called menaquinone-7 (MK-7) appears to be most active on bone. MK-7 is found in natto (fermented soy beans).

Magnesium deficiency is associated with abnormal bone formation and implicated in osteoporosis. Preliminary evidence indicates that supplementation may decrease bone loss in postmenopausal women with osteoporosis. A dose of 125 mg to 750 mg daily of magnesium hydroxide was shown to increase bone density over 2 years.

Zinc decreases bone loss and is found in high amounts in bone and muscle. Zinc deficiency is common, especially in the elderly.

Copper participates in bone modeling by decreasing bone loss and increasing bone mineralization.

Manganese is important for the building up of connective tissue and bone. There is some evidence that deficiency is associated with osteoporosis.

Boron may enhance the effects of estrogen and testosterone on bone.  Low boron in the diet is associated with calcium loss

Strontium is a trace element that stimulates bone formation and inhibits bone breakdown. A drug for osteoporosis available in Europe, called Protelos, is a form of strontium. According to Dr. Allen Gaby, MD, low, physiologic doses of strontium are more effective than high pharmacologic doses. (3) Dr. Gaby suggests that pharmacologic doses may contribute to lower quality bone formation.5

Silicon is a trace mineral found in the body, concentrated in connective tissue. Silica is silicon dioxide, a natural source of silicon found in seafood, grains, fruits and vegetables. Beer and bananas are good sources of dietary silica. Dietary intakes of silica in the range of 40 mg per day are associated with higher bone mineral density. Silicon is not to be confused with silicone, a synthetic substance used in breast implants and medical tubing.

Vitamin C is required for synthesis of bone and connective tissue.

Vitamins B6, B12, and folic acid are associated with reduced hip fractures in the elderly. Research on the bone building actions of these vitamins is preliminary and not yet well defined. The benefits on bone are related to a reduction in homocysteine, a breakdown product of protein.

Broad-spectrum vitamin / mineral supplements containing the above bone conserving co-factors are available through manufacturers that market to healthcare professionals.  Check with your doctor or pharmacist for dosages. Your physician will guide you on a comprehensive diet, exercise and supplement plan. If you are experiencing bone loss, your physician may suggest a bisphosphonate (Fosamax, Actonel, Reclast, Boniva) or raloxifene (Evista).  Drug therapy does not preempt good bone nutrition – both are required.

These statements have not been evaluated by the Food and Drug Administration. They are not intended to diagnose, cure, prevent or treat any disease. Information presented in this article is for educational purposes only and does not constitute medical or professional advice.

Resources:

• MacLaughlin, E, et. al. Management of age-related osteoporosis and prevention of associated fractures. Therapeutics and Clinical Risk Managaement 2006: 2(3) 281-295
• Rosen, C.  Postmenopausal Osteoporosis. NEJM 353:6, Aug. 11, 2005
• Jellen, J, editor. Natural Medicines Comprehensive Database. Stockdale, CA
• Bischoff-Ferrari, HA et. al. Positive association between 25-hydroxy vitamin D levels and bone mineral density; a population-based study of younger and older adults. Am. J Med. 116:634-9.
• Bone Health, by Alan Gaby, MD. Integrative Interventions
• Stendig-Evans, J, et. al. Trabecular bone density in a two year controlled trial of peroal magnesium in osteoporosis. Magnes. Res. 1993;6: 155-163
  

Pharmaceuticals in Drinking Water

By By Debbie Edson RPh , HealthyMorning.com

Most of us would not think of consuming another individual’s prescription hormones, heart medication or antibiotics. Prescription drugs, by law, must be labeled with the Federal Legend  “Caution – Federal law prohibits dispensing without a prescription.”  Yet, recent investigative reporting by the Associated Press documents that tens of millions of Americans are indeed regularly ingesting other people’s prescription drugs – in their drinking water. Veterinary drugs, including hormones used to bulk up livestock, and chemicals from personal care products are also showing up in drinking water. Trace amounts of pharmaceuticals / personal care products (PPCPs) have probably been present in drinking water for decades; however, the scope of the problem is only recently becoming evident.  Some PPCPs are endocrine disrupting compounds (EDCs) because they affect, in very low amounts, our hormone receptors.  Regulators, water treatment specialists and environmental activists are directing their attention to this newly defined class of contaminates.

How Do PPCPs Get Into Drinking Water?

When you take a drug, not all of it is absorbed by the body. The unabsorbed portion passes through the GI tract and is flushed down the toilet. The absorbed portion is later excreted in urine or feces.  Sewage treatment plants do not look for or treat excreted medications. Drugs or drug byproducts escape into the sewage treatment plant effluent. They make their way into groundwater and pass into water reservoirs, where they find their way into drinking water.  Another source of pollution is through private septic systems. Many septic systems fail to adequately contain waste. Drugs contained in the waste filter into groundwater.

What Drugs Are Found?

Hormones, especially estrogen, antibiotics, pain medications, heart medications, cholesterol lowering drugs, caffeine, anti-epileptic drugs, anti-depressants and tranquilizers have been found.

How Widespread Is the Problem?

Most water utilities do not routinely test for PPCPs, and if drinking water is tested and PPCPs are found, the water provider is not required as yet by the EPA to make the information public. According to the AP investigation, drugs have been found in 24 major cities across the US. In Philadelphia, 56 different pharmaceuticals or their degradation byproducts were found in treated drinking water.  Sixty-three pharmaceuticals were found in Philadelphia’s watersheds. Drinking water supplies for Southern California, Northern New Jersey, Washington, D.C. and San Francisco also tested positive. Only 28 of the 62 water providers contacted by the investigators submitted to water testing. Among the 34 that did not undergo testing were New York, Boston, Houston, Chicago, Miami, Baltimore and Phoenix. Consequently, the AP report documents only a portion of the problem.

Rural areas do not escape the presence of PPCPs. According to a report in the February 2008 Chemical & Engineering News, the American livestock industry generates 500 million tons of waste per year. Livestock waste is a tremendous source of antibiotics, synthetic hormones and other pharmaceuticals. Contaminated soil is a vehicle for delivery of drug waste to humans. Earthworms take up contaminates into their tissues, which are then transferred up the food chain. Additionally, crops, such as lettuce and carrots have been shown to take up veterinary drugs, according to a 2006 study in the Journal of Agricultural and Food Chemistry.

Regulation and Treatment

The Federal government regulates contaminants in drinking water under the auspices of the Environmental Protection Agency (EPA). The EPA as yet does not require testing for PPCPs and has not set any standards or limits. The EPA maintains a “Contaminant Candidate List (CCL), which identifies contaminants in public drinking water that warrant study. PPCPs are not yet on the CCL. In April of this year, a US Senate subcommittee on Transportation, Safety, Infrastructure Security and Water Quality heard expert testimony on PPCPs. Participants blasted the EPA for not taking action on the problem.

PPCPs occur in drinking water in parts per billion or parts per trillion. Controversy exits over the heath effects of such low concentrations. In the past the EPA regulated drinking water contaminants by enacting regulations on a chemical by chemical basis, setting minimum allowable levels, above which treatment of the water supply is mandated. With regard to PPCPs, this approach is probably impossible both from a practical and cost effective standpoint because of the vast array of possible contaminants which occur at extremely low concentrations.  Less expensive drinking water treatment options, such as simple filtration methods, are not effective. Single treatment technologies are also not likely to be effective. More costly treatment technologies, such as reverse osmosis, ultraviolet light and advanced oxidation techniques used in combination are being investigated.  Identification of viable treatment technologies is in its infancy – there are no quick, easy solutions.

Are PPCPs A Health Threat?

We don’t know if PPCPs are harmful to humans.  Experts disagree on potential health effects of these extremely low level contaminants.  We do know that they are having a profound effect on wildlife in certain locations. In December 2007 the Journal of Aquatic Animal Health and the US Geologic Survey reported that male fish in the Potomac River were feminized. Small mouthed bass had immature female egg cells in their testes. The numbers of these fish increased in areas with the highest levels of PPCPs.  Intersex fish have been found in the Great Lakes, the Mississippi River, Denmark, Japan and South Africa.

Drugs are designed to work on human enzymes and hormone receptors at low levels. Although adverse effects of PPCPs in humans have not been shown, they have not been studied either. The developing fetus may be extremely sensitive, especially to low levels of hormones. The elderly and the very ill or immune compromised may be at higher risk. Even though levels are low, exposure may occur over decades.  If the drinking water contains a “cocktail” of PPCPs, then it is anyone’s guess what adverse events may result. The scientific method, our gold standard for analyzing the universe, is not good at studying the effects of multiple and inconstant variables. We may have to resort to an out of date, primitive tool – our common sense!

Can You Help?

Don’t flush medications down the toilet or put them down the sink.  Ask your local Health Department if they have an environmentally safe disposal system for unused drugs. If they do not, how about starting one? Another option is to ask your local pharmacy if they have a program for discarding unused medication. France has implemented a program for recapturing unused pharmaceuticals. With each prescription a prepaid mailer is handed out so people can return unused drugs.  The French program has been very successful. Simple measures such as these may have a huge impact in reducing contamination with PPCPs and reduce the need for costly treatment systems.

Resources

• Meds Lurk in Drinking Water. Jeff Donn, et al. Associated Press Investigative Report. MSN.com March 10, 2008

• In A Green World, Do Pharmaceuticals Muddy the Water? The Pharmacist, May 2008

• Emerging Contaminants – Insights to the Most Effective EDC and PPCP Treatment Strategies. OpFlow May 2008

• Senate Hearing Sounds Alarm on Pharmaceuticals. E-MainStream AWWA 4/22/08

• Side Effects – Chemical & Engineering News. Feb. 25, 2008

Debbie Edson is a registered pharmacist, with a background in hospital and community practice. She is proprietor of Healthy Morning, LLC. Her passion is educating people about evidence based natural healing. She is a recent contributor to the best selling book, Prescription For Nutritional Healing, 4th Ed She can be reached at Debbie@healthymorning.com

Bio-identical Hormones For Women – Are They A Safe Alternative?

By Debbie Edson R.Ph.

In response to studies linking the use of hormone replacement therapy (HRT) and breast cancer, many post-menopausal women look for alternatives. One of the more popular alternatives to conventional HRT is the use of “bio-identical hormone” therapy (BHRT).  Prompted by celebrity endorsement, promises of safety and anti-aging benefits, some woman seek compounding pharmacies that will, upon prescription, make personalized formulas of hormones to replace the those naturally waning after menopause.

Recently, the FDA cracked down on claims made by some compounding pharmacies regarding BHRT, calling use of the term, “bio-identical” unscientific. The FDA is not discouraging the use of compounding pharmacies. Specifically, the FDA cracked down on claims for one of three estrogens used in BHRT, estriol. Estriol is a weaker estrogen and promoters of BHRT claim that it does not increase the risk of breast cancer.  The problem is that claims regarding the safety of estriol have never been proven in clinical trails.

Frequently Asked Questions

To help clarify the situation for women, several frequently asked questions are addressed.

What are bio-identical hormones?

The term “bio-identical” was coined by MDs who practice natural medicine and by naturalpaths and by compounding pharmacists about 15 years ago.  Bio-identical hormones have the exact chemical structure as those produced by the human body. Three estrogens are typically incorporated into BHRT formulas – estrone (E1), estradiol (E2), and estriol (E3). Estrone is about 1/3 as potent as estradiol; estriol is about 1/5 as potent. Typically, bio-identical estrogen formulations are at least 80% estriol. Preparations also may include progesterone and testosterone.

Are bio-identical hormones “natural hormones”?

No, they are not “natural” because they are made in laboratories.

Are bio-identical hormones safer than conventional HRT?

There is no evidence that bio-identical hormones are safer. Doctors with years of experience using BHRT believe they are safer, but there are no well-designed clinical trials to verify their position. Women who decide to use bio-identical hormone therapy should do so with their eyes open.  This author strongly advises that you use your regular physician, not someone you find on the Internet. Regular checkups, mammograms, self-examination are as important as ever. Do not be lulled into complacency. If you are using progesterone and / or testosterone, in addition to estrogen, keep tabs on your blood pressure and cholesterol levels.

Observational studies that look at the number of years a woman menstruate, and relate that variable to the incidence of breast cancer shed light on the question of safety. Women who begin menstruation earlier in life and / or go through menopause later than the norm have a higher risk for breast cancer. In other words, women who go through a longer time exposed to their own, bio-identical estrogen are at greater risk for breast cancer than those who spend fewer years of their life exposed to their own estrogen. Based upon this information, in this author’s opinion, it is prudent to assume that both HRT and BHRT carry breast cancer risk.

Is bio-identical progesterone safe?

Bio-identical progesterone is claimed to be safer than its synthetic counterparts, which are collectively called progestins. The most commonly used progestin is medroxyprogesterone.

In the Women’s Health Initiative Trial, the study arm that took Prempo® (a combination of medroxyprogesterone and conjugated equine estrogen) had a higher risk of breast cancer compared to placebo. Scientists surmise that, while estrogen stimulates the growth of breast cancer, progestin increases the blood supply to tumors, facilitating growth. Bio-identical progesterone has the same effect on breast tissue, so there is no reason to assume it is safer than progestins with regard to breast cancer. After menopause woman make estrogen in fat tissue. If you have a significant amount of estrogen, even though you are post-menopausal, and you use OTC progesterone, you may be increasing your risk of breast cancer.

Topical progesterone products are available over the counter. This author advises that they not be presumed to be safe. Some women experience elevated blood pressure from these products.

Do drug companies make bio-identical hormones?

Yes, drug companies have been making bio-identical hormones for years, in pill, patch and vaginal products. Estradiol is used in many pharmaceutical preparations.

Difficult Decisions

Today, most doctors use HRT for menopause symptoms only and for the shortest length of time possible. Proponents of BHRT, however, present it as a way to prevent or reverse aging. Estrogen does protect bone and soft tissue. Post-menopausal women, when pondering the use of estrogen, face a “breast vs. bone” decision.  Hopefully you now have some additional knowledge so that you, along with your physician, can better address the decisions at hand. 

These statements have not been evaluated by the Food and Drug Company. They are not intended to diagnose, cure, prevent or treat any disease.