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Osteoporosis is a preventable condition.

Vitamin D and Osteoporosis Prevention

Vitamin D and Osteoporosis Prevention

Vitamin D is back in the news again.

You may have seen recent news claiming vitamin D supplementation fails to prevent osteoporosis, fractures or falls.  Published in the Lancet — a Systematic Review and Meta Analysis paper dated October 04, 2018 from the Department of Medicine, University of Auckland, New Zealand and the Health Services Research Unit, University of Aberdeen, Scotland, UK.  They conclude and state at the end of a complex meta-analysis

“we believe there is no justification for more trials of vitamin D supplements with musculoskeletal outcomes because there is no longer equipoise about the effects of vitamin D on these outcomes.”

Rather strong conclusion designed to forestall any further investigation or discussion.  Really?

Now personally, I owe my interest in vitamin D supplementation to my good friend Dr. William Grant of SunArc.  And work that has been done by Dr. John Cannell, who founded the Vitamin D Council headquartered in Marina del Rey, California.  Both are superb sources of ongoing vitamin D research.

A meta-analysis is a literature review of all relevant resource papers.  It suffers from specificity and accuracy of database key words, capture and design.  It is limited by various assumptions, and highly intricate statistical conventions.  Studies are excluded or included based on assumptions of the authors.

One of my current criticisms of all these citations is failure of a popular news article to actually cite the source.  So we cite here.  Effects of Vitamin D supplementation on musculoskeletal health: a systematic review, meta-analysis and trial sequential analysis.  You will have to pay to actually read this paper.  So, I will summarize for you.

The paper is exhaustively written and detailed.  But suffers from a number of limitations and dubious pharmacologic assumptions.

First, it is stated that there was no difference between high-dose vitamin D and low dose vitamin D.  What defines high-dose and low dose?  Low dose was <800 units per day.  High-dose was >800 units per day.  I always have issue with “greater than” or “less than” because of a lack of specificity.   >800 could be 801, 1000, 5000 or 50,000.  You don’t know.  <800 could be 799, 700 or 100.  To be somewhat facetious.  But it is highly important because we don’t know from their study.  What would be the ideal dose of vitamin D?   Who decided on this magical 800 units number?

In fact, that is where 80% of all medical and scientific studies fail.  Who chooses the ideal dose?  On what basis is an ideal dose determined?

I often use a facetious example of Lipitor.  Lipitor will lower your cholesterol.  More specifically, your LDL values.  I could design an experiment using 1 mg of Lipitor for one year.  You will see no benefit.  It is too low.  A study using 1 mg would conclude Lipitor is a worthless drug.  In the other hand, let’s use an arbitrary dose of 100 mg of Lipitor for a study.  After one year I would conclude this is a highly toxic drug causing muscle pains, memory losses and liver abnormalities.  A drug that is too dangerous.  So at some point, scientists determined that the ideal dose of Lipitor is 10 to 40 mg.  With a certain segment of the cardiology community is using extremely high doses of 80 mg.

Dose-response.    A fundamental tenant of good pharmacologic design and use.

Now back to vitamin D.  We are told that the levels achieved were were either >50 nmol/l or >75 nmol/l.  Again we have the problem with the specificity of “greater than.”

Furthermore, most commercial clinical labs report in ng/ml not nanomoles/l.  So  >50 nmol/l  =  >20 ng/mL and >75 nmol/l = >30 ng/mL.  What does this mean?

Vitamin D testing (using GC/MS/MS) is one of the lab tests that that is rationally graded on a continuum. Not simply high or low cutoffs. <15 ng/ml is (severely) deficient.  15 to 30 ng/ml is insufficient.  30 ng/ml to 100 ng/ml is sufficient.  > 100 ng/ml is excess.  And >150 is considered toxic.  Never mind, that it is not toxic.

So that this meta-analysis using a “high value” of >75 nmol/ml  ( >30 ng/mL ) is not high.  It is barely therapeutic.  Just barely at the very lower limits of therapeutic.  Like driving a car with a 1/4 tank of gas.

Personally, and in the Anti-aging / Nutritional Medicine community a consensus seems to be a daily dose of 5000 units is the average starting dose for the overwhelming majority of our patients.  Aiming for 60-80 ng/ml blood values.  That seems to be the ideal dose and value.  There are individual variations so that some of our patients will require 10,000 and 15,000 or as high as 20,000 units daily to achieve good therapeutic levels.  In rare cases patients only need 3000 units.   But clearly 800 units is nearly useless.

So this meta-analysis suffers from so many shortcomings.  A meta-analysis is a poorly controlled study because it is a retrospective look at a host of studies all probably suffering from experimental design weakness.  Then there is the highly intricate retrospective statistical conventions excluding and including various studies for capricious reasons.  Starting with a completely capricious and arbitrary dose and level.  And finally, we have no idea whether blood levels were drawn at one time during a study or weekly or monthly or the beginning or the end.  Most likely levels were drawn very infrequently and then assumed to be constant through the study.   Probably None of these studies were carried longer than one year.

Finally, Vitamin D alone is probably insufficient to enhance bone integrity and prevent osteoporosis.  Empirically, I have observed osteoporosis is prevented by a combination of estrogen or testosterone vigor, vitamin D3, vitamin K2, the right balance of calcium and magnesium, and light weight bearing exercises.  A study simply looking at the efficacy and levels in potency vitamin D will never prove the assertion that osteoporosis cannot be prevented by vitamin D.

There are some political considerations.  The US Preventive Services Taskforce specifically recommended against Vitamin D supplementation to prevent fractures or falls.  They intentionally excluded all of the known experts in vitamin D.  Of which there are only 4 or 5 notable vitamin D researchers in the world.

So beware.  This meta-analysis or study does not prove that vitamin D is either inadequate or useless.  I personally  recommend vitamin D at least 5000 units daily,  Vitamin K2 15 mg,  800-1000 mg calcium 200-600 magnesium, weight-bearing exercises and evaluation of your hormonal status.  This is simply a starting point.  There is considerable variation from patient to patient.  That is why you need expert advice and counsel.   Reference my earlier blogs on Osteoporosis Prevention.   And the importance of Vitamin K2.

Reader beware.

Philip Lee Miller, MD

Carmel CA

Vitamin K, Calcification and GLA Proteins

Vitamin K, Calcification and GLA Proteins

Vitamin K2 is a potent anti-calcification nutrient via GLA protein carboxylation.  Let’s look at this process of calcification and the potency of these various forms of vitamin K2.   Then talk about the MK-4 vs Mk-7.    Which is best for you?   And why?

Vitamin K2 forms

There are currently three forms of vitamin K available. Vitamin K1 (phylloquinone) has been extensively studied. It is not the most potent form. Vitamin K2 is currently available in two forms. MK-4 also known as menaquinone-4 or menatetranone. MK-7 (menaquinone-7) is currently advocated as the most potent form of vitamin K2. You can see in fig 1 that the MK-4 and MK-7 have long “tails” with multiple (poly unsaturated) double bonds.  This increases lipid solubility.  These are fat soluble as opposed to water vitamins.

Vitamin K1 and vitamin K2 MK-4 MK7
fig 1

So what is the connection between Vitamin K2 and tissue calcification? Why do we petrify as we grow older? Why do we grow stiffer? This is a combination of calcification and glycation.  Glycation is secondary to excess carbohydrates, rising hemoglobin A1c (>5.6%), and impaired fasting blood sugars (>100 mg).

Calcification is an impaired healing process. Arterial injuries initiate a process of calcium deposition as a repair mechanism. Calcification is the end result of chronic inflammatory processes.   This is a key concept.

How can we prevent or reverse this ossification process?

Read More Read More

Osteoporosis detection and prevention

Osteoporosis detection and prevention

Osteoporosis — the preventable epidemic

California Age Management Institute

Osteoporosis.  Now you thought this was a problem of 70 and 80 year olds. What was once heard described by a patient quoting her physician, “well, Mabel it seems you have moldy bones.” But some of the largest and well known HMOs won’t even begin testing for this until after 60 — until it may be quite late in the game.  So why be concerned?

aging osteoporotic bones
osteoporosis with advancing age

Osteoporosis by definition is a lack of bone strength — leading to a fragile structure usually characterized by a lack of calcium. It

is technically a decrease in bone mineral density which is best diagnosed by a DEXA (dual energy x-ray absorption) scan. But calcium (or milk and dairy products) alone, contrary to such popular belief is not enough. By way of example, a piece of chalk is loaded with calcium carbonate and we all know how strong simple chalk can be — not very. Why suggest that both men and women start checking for this in their early 40’s rather than waiting until much later? Maybe it has to do with current eating patterns. Maybe … it has to do with …prevention.

It is a painful sight to this physician and writer to see patients shuffling past an office window, stooped over a haltingly advancing walker. It is all so preventable. Hopefully, you are whispering — not for me.

At variable rates of aging or even extreme athletic competition is a subtle and then progressive outflow of calcium from bones. We are withdrawing calcium from “the bank” Our bones, seen as the skeletal support that keeps us upright, remains our main reservoir and “bank” for total body calcium. The outflow eventually moves into the blood vessels, heart valves and tissues. High performance athletes actually accelerate this shift much earlier.

What controls this process? It is a complex set of hormones, including testosterone, estrogen, progesterone and parathyroid hormone; minerals including calcium, magnesium, strontium, boron; and the vital regulatory Vitamins D3 and K. But there is a greater culprit lurking.

Carbonated Soft drinks.

These ubiquitous little companions have high concentrations of phosphoric acid which gives it the fizz. But phosphoric acid is a superb calcium chelator, meaning it sucks calcium out of the bones with vigor. So to an entire generation that is waking up to carbonated soft drinks, diet or otherwise, we are filing up the tank with powerful calcium thieves. And this is why the “epidemic” could reach such alarming levels in the next decade or two. Osteoporosis, the “disease” of the “elderly” is going to be more commonly diagnosed in mid forty year old women and, who knows, younger.

The good news — osteoporosis is preventable.

This is where Anti-Aging Medicine can begin to realize the promise of a new paradigm. If we can begin to see that some gentle shifts in eating habits, and modest exercise, and the proper consumption of true “bone builders” loaded with a healthy balance of calcium, magnesium and more, then the answer is upon us.

The iconic images of Sophia Loren, John Glenn, Jack LaLaine and Clint Eastwood give us positive pause. Vigorous, fit, mobile and youthful members entering seventh, eight and even ninth decades. We all have a choice.

There is the offer of various drugs such as Fosamax and Evista and others to reverse this process. This caters to the old model of drive-through medicine — fix me up now that the process has resulted in a fracture of the hip or the backbone (lumbar vertebrae). But those of us in the baby boom population have a different answer. Active and progressive prevention.

And you have another advantage — the sun. Recently vilified as causing wrinkly skin and skin cancers, the Sun is your most important source of Vitamin D. This is the up and coming micronutrient that is essentially free and widely available in Florida. Modest and brief “unprotected” exposure to sunlight can produce as much as 10,000 units of Vitamin D daily. This is one of the crucial regulators. Healthy vitamin D that is at low levels in more Northern climates. Vitamin K2 remains the other vital nutrient available in foliage vegetables and as a supplement from select companies.

Take these healthy precautions, and ask for DEXA scanning in your 40s and a brisk upright, confident walk and stance remain in your future.

As we say, it’s up to you and it’s about time …

Philip Lee Miller, MD
Founder, California Age Management Institute  [formerly Los Gatos Longevity Institute]
Author, the Life Extension Revolution
March 2, 2006

Originally published in the Affluent newspaper

California Age Management Institute
Monterey, CA, USA
(408) 358-8855 tel
(408) 358-8855 fax

copyright © 2006-2016 ™ and California Age Management Institute (formerly Los Gatos Longevity Institute).
All rights reserved.
Most recent update: January 11, 2016


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