Calcium, Vitamin D, And Fractures In The Elderly...not worth supplementing?

Uncategorized Jan 17, 2018

All right. Happy Monday. Wanted to go over an article I read recently. This one is about vitamin D and calcium supplementation in elderly population in what I would call nursing homes. They call them community dwelling older adults. So I guess the new PC way to say that, so we want to be sensitive. So association between calcium and vitamin D supplementation and fracture incidence in community dwelling older adults. This was in the Journal of American Medical Association, 2017, it looks like December 26th, so pretty recent.

        Interesting article, interesting take home message from it but I kind of think they missed the mark on the way they did this. So here's what they did. They were looking to find out whether or not vitamin D and calcium supplementation either individually or together made any difference in fracture rates in elderly individuals that were not living in their home pretty much. But the way they went about it is they went back through lots of other research. They did what's called a meta analysis where they just pull other research stories and bring all the data together and try to rework the data to get an answer to something like this. And in a lot of cases you can get decent information that way, in other cases you lose enough control over the situation that it's hard to get anything that's actionable or, what we would call generalizable to the population you're looking at.

      So they had, I think when you add up all the participants in this, they had 51,145 people through all these studies that they pulled and they basically found that whether people were taking calcium supplements, whether they were taking vitamin D supplements or whether they were taking a combination that had calcium and vitamin D in them, there was generally no difference in the rate at which these people were getting fractures. So therefore supplementing this population with calcium and vitamin D makes no difference in their fracture rates. And I think for the information at which they looked, they probably drew the right conclusion.

      But what jumped out at me is first of all the timing of it. They aren't doing this in their 40s and 50s to find out what fractures rates are later in life. It's almost like you're supposed to put in your retirement account in your 20s, 30s, 40s predominantly so that there's money growing and it's available for you in your 60s and 70s and 80s. It's kind of like going to people in their 70s and saying, well these people are running out of money, does putting $200 a month in their retirement account make much of a difference? No, so don't bother putting money in your retirement account. If you had put that $200 a month in your retirement account back in your 20s, by the time you're in your 70s, it makes a substantial difference.

         So they are only looking at supplementing people at the tail end of this, when the fractures are actually occurring. Kind of looking at making deposits in your retirement account once you're running out of money. That's one of the first problems I see. The second problem I see is we don't know what dosage or form of vitamin D or calcium these people were taking. For that matter, I suppose if you're taking One A Day multivitamin, it's got some calcium and it's got some vitamin D in it, does that count as supplementing them with calcium and vitamin D? Is that a meaningful amount? Was that person deficient in vitamin D to begin with? If they separated these people into populations who were deficient in vitamin D and calcium and ones who were sufficient in vitamin D and calcium, would they have found a difference in fracture rates in the group that were brought from deficiency up to being normal? Would they have had fewer fractures? We don't know. They didn't divide the data out that way. So we don't know what dosage they were given. I'm sure there were hundreds of different dosages across the board ad there was no difference in fracture rates.

     To some degree, you would say, well if we covered lots of different dosages then we should still have an accurate statistical analysis, but when you look at the dosages that are out there on the market today, most nutritionists or functional medicine doctors, people that use nutrition as a tool would not consider the dosage that's in your One A Day multivitamin a therapeutic dose of calcium or vitamin D in most cases. And you deal with the form of it. Was the form even something that was absorbable.

                             That brings us to another point. How many of these patients were also taking acid blockers? Nexium, Prilosec, Zantac, any of the, what we call H2 blockers or PPI inhibitors. If they are on acid blockers like that, they're not going to absorb minerals anyway whether you supplement them or not because it requires an acid environment in the stomach to absorb those minerals. So again, pull out the group of seniors that are taking those medications because their supplementation is probably largely irrelevant any way, and have sub population of only people that have adequate stomach acid taking their mineral and vitamin D supplementations and you might have had a different answer.

       So you're starting to see how the problems with the study are adding up that you really can't make a general statement at the end of it that the supplementation is either worthwhile or not based on research like this. They just didn't narrow in on the population that they were studying well enough to do that. We've talked about blood levels of vitamin D in the past that I prefer my patients to have a blood level of vitamin D somewhere over 55. I think that's more appropriate in the human condition to have that. I think that's where vitamin D is able to do a lot of the things that it's designed to do in us, but many doctors feel that anything over 30 is appropriate. In my patients who have issues that would indicate that they don't have enough vitamin D, they have inflammatory conditions, they have cancer, they have immune related issues. I think those people do better in range from about 70 to 90 on their blood test. And many people disagree with that and think they should 30 and above and that's normal.

       So there's a lot of discrepancy on vitamin D levels, but it would have been interesting to see if vitamin D levels in the patient made a difference in fracture incidence. So anyway, the article just doesn't tell us much. Another thing I want to bring up that isn't talked about in these situations is the importance of collagen. Collagen makes the framework of the bones much like the 2x4s make the framework of your house, and that is a somewhat, I would say moderately flexible framework. It doesn't get rigid until you add all the siding and brick and mortar, sheet rock and plywood and all of that on top of it. Those are kind of the minerals of the bones, but collagen is that semi flexible framework. And in many cases, when people take medications to increase the density of their bones, that just increases the amount of siding that's put on their to make it rigid. If you don't rebuild that collagen framework, you lose that little bit of flexibility in the bones and you're at greater risk for fracture anyway. It becomes dense but more brittle as opposed to more flexible.

       We know that if you wiggle your nose, it's much more flexible than if you try to wiggle the bone in your arm. That's because the nose is predominantly collagen. The arm is collagen that's been mineralized into a much more rigid product. So having stomach acid available, getting the right amount of collagen, allowing the bones to break down and reform when you take medications for bone density. Quite often what they do is they stop you from breaking down the bone and all you can do is add to it. Now, on the surface, that's sounds great but think of a road out there that we drive on. If you're never allowed to tear it down, all you can do is put layer upon layer on top of it. That doesn't give you a better and better road over time. Yeah, it's kind of smooth when you put a new layer on, but if the underlying layer just keeps getting worse, laying more on top is not going to fix the problem. You actually need to chew up that road and lay a whole new one.

     Well that's what the osteoclasts in our body do. They're cells inside the bone that work along and chew up that bone, collagen included, and then the osteoblasts come behind that and lay down new bone, including the collagen. In the medications you take for bone density, they stop the osteoclasts from every chewing it up but the osteoblasts can continue laying down more mineral. That does, in many cases, produce a more dense bone but not a more functional bone. It can become dense and brittle but when you do bone density test, it looks better. So bone quality is not all that simplistic anyway but what bothers me sometimes is an article like this will show up on your local news station as, hey Journal of the American Medical Association says supplementing elderly people has nothing to do with how often they fracture bones, although supplements are just a load of crap and that's what people hear. That's what other doctor's hear and they just take it at face value.

       But when you really dig into the article, there's very little substantive information there. I think it borders on just basically being misleading. Now, to be fair, do I think if I find a 75 year old person with brittle bones and I just put them on calcium and vitamin D supplement, is that going to make everything better? No, I don't think it will. But I don't think that it has no value in the entire population. They still need to have an appropriate vitamin D level, they still need to get calcium. They need to be able to absorb it. And honestly, weight bearing exercises is one of the best things you can do to build bone and encourage your body to reform that bone and make it functional. It's difficult to get those people in that population to safely do weight bearing exercise. Vibration plates are a great option. Stand them on a vibration plate and it almost mimics the stress on the bones that you get from exercise and it encourages reforming of those bones, if they're not on a medication that stops them from reforming the bones.

        So anyway, I know that gets very confusing as I go through that, but for those of you have elderly family members or you're familiar with some of these medications and you know how they work, this should make some sense to you. But I wanted to point out, I did a video a while back on some of the pitfalls in medical research, this is an example of research that's not lying to you, but I think it's definitively trying to mislead you, if that makes any sense. So anyway, wanted to throw that out there. Again, let me know your comments and your thoughts on this. More than happy to answer questions that you put in the comments under here. I'll check on them later today, and hey, we're right up against apparently snowmageden here in Houston tomorrow, so I may be answering question all day anyway.  We'll see how that turns out. Until I talk to you next time, as I always say, eat for your health, train for performance and live the life you love today. Thanks for watching.

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