Category Archives: Osteoporosis

Red Sox Players Should Manage Their Vitamin D and Melatonin Status

Posted by on October 13, 2010 44 comments

Everyone should routinely measure their 25-hydroxyvitamin D status and use sun exposure or vitamin D3 supplementation to attain a level around 40 ng/ml.

This is especially important for those whose occupations keep them out of the sun. Night workers, especially, may have difficulty manufacturing sufficient vitamin D.

In my last post on the amazing and unnatural fragility of Red Sox players’ bones, I didn’t discuss vitamin D – a crucial nutrient for bone health, and health generally – because I thought that baseball players must get a great deal of sun exposure.

But on second thought, that may not be the case.

The Red Sox Are Night Workers

Most games start in the evening, around 7:05 pm. Games typically last between three and four hours. Players often eat a post-game meal at midnight, and may not sleep until 2 or 3 am. On road stands, every third game is followed by travel, so that players arrive in the new city early in the morning. As it is often difficult to sleep on planes, it’s reasonable to guess that many players sleep during daylight hours.

Night Workers Are At High Risk for Fractures

The Nurses’ Health Study found that night workers generally had a 37% higher risk of bone fractures. But slender night workers – those with a BMI below 24 – had a 136% higher risk of fractures. [1]

Jacoby Ellsbury, with the most fragile bones on the Red Sox, is one of the more slender players, and might be particularly vulnerable to the night work effect. At 6’1”, 185 pounds, his BMI is 24.4.

Vitamin D Is Crucial for Bone Health

Bone mineralization is optimized at serum 25-hydroxyvitamin D levels near 40 ng/ml. [2] Randomized controlled trials have found substantial reductions in fracture rates with vitamin D supplementation, for instance a 58% reduction in non-vertebral fractures and a 37% reduction in hip fractures. [2]

Even slight deficiencies can weaken bones. In mild vitamin D deficiency, serum PTH becomes elevated in order to increase conversion of 25(OH)D to the more active form of 1,25(OH)D to compensate for the insufficiency of 25(OH)D; however, elevation in PTH increases bone resorption, leading to additional bone loss. [3]

Vitamin D Optimization Improves Athletic Performance

In addition to its effects on bones, Vitamin D is also critical for muscle function and coordination. [3] Prolonged vitamin D deficiency is associated with severe muscle weakness which improves within several weeks of vitamin D supplementation. [4] In another study, quickness of movement was proportional to serum 25-hydroxyvitamin D levels. As the 25(OH)D level rose from 9.0 to 37.6 ng/mL, time to perform an 8-foot mobility test decreased by 0.67 seconds. [5] In another study, vitamin D supplementation reduced the rate of falls by 49%. [2]

For elite athletes, optimizing vitamin D can make a significant difference. After noticing that athletic performance was consistently better in summer than winter, the East German and Soviet athletic machines began programs of vitamin D supplementation. These programs coincided with the rise of these nations to the top of the Olympic medal lists. [6]

Melatonin Is Also Important

Melatonin, the “hormone of darkness,” is released during sleep, but only under conditions of quiet and darkness. Even a small amount of light can disrupt melatonin production.

Melatonin has both direct and indirect effects on bone. [7] It directly affects bone mineralization and activity of osteoclasts and osteoblasts – the two cell types responsible for bone remodeling and healing – and indirectly affects bone through its effects on other hormones such as cortisol. Melatonin levels tend to decline with age, and this may be responsible in part for the higher rates of osteoporosis in the elderly. In rats, melatonin co-participates in bone loss in a model of osteoporosis. [8]

Melatonin may also help athletic performance. In rats, 4 weeks of melatonin supplementation just before sleep led to reduced lactate levels during exercise, delayed exhaustion, and increased glycogen reserves. [9, 10]

Conclusions

Everyone, but especially professional athletes who work at night, should monitor serum 25-hydroxyvitamin D levels and get sun exposure or D3 supplements at mid-day to achieve 40 ng/ml.

Everyone, but especially professional athletes who work at night, should sleep in rooms with totally opaque drapes, so that the room remains completely dark after the sun rises, until natural waking. Artificial light sources should be eliminated, for instance by turning LCD clocks face down. Melatonin supplementation may also be worth consideration, especially in the elderly or those suffering from chronic infections; time-release melatonin at bed-time is optimal.

These steps will help optimize status of two hormones crucial for bone health and, possibly, athletic performance.

Maintaining optimal vitamin D and melatonin status is tricky for night workers. It should be a priority for the Red Sox. Have they done it?

References

[1] Feskanich D et al. Nightshift work and fracture risk: the Nurses’ Health Study. Osteoporos Int. 2009 Apr;20(4):537-42. http://pmid.us/18766292.

[2] 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. 2004 May 1;116(9):634-9. http://pmid.us/15093761.

[3] Lane NE. Vitamin D and systemic lupus erythematosus: bones, muscles, and joints. Curr Rheumatol Rep. 2010 Aug;12(4):259-63. http://pmid.us/20429045.

[4] Prabhala A et al. Severe myopathy associated with vitamin D deficiency in western New York. Arch Intern Med. 2000 Apr 24;160(8):1199-203. http://pmid.us/10789615.

[5] Bischoff-Ferrari HA et al. Higher 25-hydroxyvitamin D concentrations are associated with better lower-extremity function in both active and inactive persons aged > or =60 y. Am J Clin Nutr. 2004 Sep;80(3):752-8. http://pmid.us/15321818.

[6] Cannell JJ et al. Athletic performance and vitamin D. Med Sci Sports Exerc. 2009 May;41(5):1102-10. http://pmid.us/19346976.

[7] Cardinali DP et al. Melatonin effects on bone: experimental facts and clinical perspectives. J Pineal Res. 2003 Mar;34(2):81-7. http://pmid.us/12562498.

[8] Ostrowska Z et al. Assessment of the relationship between dynamic pattern of nighttime levels of melatonin and chosen biochemical markers of bone metabolism in a rat model of postmenopausal osteoporosis. Neuro Endocrinol Lett. 2001;22:129–136. http://pmid.us/11335889.

[9] Kaya O et al. Melatonin supplementation to rats subjected to acute swimming exercise: Its effect on plasma lactate levels and relation with zinc. Neuro Endocrinol Lett. 2006 Feb-Apr;27(1-2):263-6. http://pmid.us/16648794.

[10] Kaya O et al. Effect of melatonin supplementation on plasma glucose and liver glycogen levels in rats subjected to acute swimming exercise. Pak J Pharm Sci. 2010 Jul;23(3):241-4. http://pmid.us/20566433.

Are the Boston Red Sox Malnourished?

Posted by on October 11, 2010 45 comments

Last Thursday’s post was mainly concerned with Abby’s bone injury that refused to heal. I noted that four nutrients – vitamins C, D, and K2, and magnesium – were essential for bone health, and that deficiencies could have contributed both to Abby’s injury and her slow healing.

Today’s post is about another group of people who frequently break their bones and don’t heal well:  the Boston Red Sox.

Injury-Prone Sox

Those who follow baseball may know that a promising 2010 Red Sox season was sabotaged by a rash of broken bones:

  • Centerfielder Jacoby Ellsbury missed 144 games with hairline fractures in four ribs; they failed to heal properly and re-fractured months after the initial injury.
  • Second baseman Dustin Pedroia missed all but two games after breaking his foot June 25.
  • Catcher Victor Martinez missed a month with a broken thumb.
  • Backup catcher Jason Varitek played just five games after breaking his foot on July 2.

There were muscle and joint injuries too, but let’s stick to bones.

Is it possible the Red Sox players are suffering from micronutrient deficiencies?

The Red Sox Hire a Dietitian

A few years ago the Red Sox hired a professional dietitian to advise their players: Tara Mardigan of the Dana-Farber Cancer Institute.

Ms Mardigan is a lovely woman, a marathoner and former gymnast, with a charming personality that shines through in radio interviews. She obtained her position with the Red Sox after meeting Red Sox president Larry Lucchino at a charity breakfast.

But what is her diet advice, and which players are taking it? I found a hint about the latter question in an interview in the student newspaper at Tufts University’s Friedman School of Nutrition Science, where Ms Mardigan studied:

I stopped working full-time at Dana-Farber to accommodate working with the Red Sox, and luckily they have a great relationship with the team so I was able to reduce my hours.  I also work with the Red Sox’s minor league teams, the Lowell Spinners, Pawtucket Red Sox, and Portland Sea Dogs. This is where I really make changes.  I work with young guys who are interesting in learning about how nutrition can improve their performance.  They are hungry to get to the big leagues. It’s great to see them move up into the major league, and then become someone like Jacoby Ellsbury (Left Field/Center Field) who is now well-versed in nutrition.

Uh oh! Jacoby Ellsbury, who managed only 18 games in 2010, whose bones break on incidental contact and whose hairline fractures won’t heal in six months, is the dietitian’s prize pupil?

The Dietitian Advises Avoiding Supplements

The Friedman School interview didn’t tell us much about Ms. Mardigan’s dietary recommendations, other than that she opposes most nutritional supplements:

I try to get them to choose food before supplements, and only supplements when necessary. Athletes are vulnerable and think [supplements] are well made and well regulated, and they are shocked when they find out they are not.

Those who have read our book know that we have a chapter titled “Why Moderns are Malnourished” which explains why modern agriculturally-produced foods and treated water don’t provide enough micronutrients, and why supplements are needed to optimize health.

Among the micronutrients for which supplementation is most needed are vitamin K2 and magnesium – two crucial nutrients for bone health.

What Is Her Diet Advice?

To get an idea of what diet she might be recommending, I looked at the Dana-Farber nutrition team web site, and was surprised to see this graphic illustration of their “Optimal Diet plan for cancer survivors”:

Yikes! No fats, and no mention of healthy plant foods like starchy tubers. A quarter of the diet is toxic grains and the protein may be derived from toxic legumes. It looks like roughly 70% of calories come from carbs and 25% from protein.

Later in the page they suggest such omega-6-rich oils as soybean oil, canola oil, flaxseed oil, wheat germ oil, and walnuts – all eliminated on the Perfect Health Diet.

It seems Ms Mardigan has recommended a similar diet to the Red Sox. From the Dana-Farber site:

On staff with the club since January 2006, she attends most home games to meet with players and make sure grilled chicken, steamed vegetables, and other healthful options are available in the team dining room.

Vegetables and lean protein, just like the Dana Farber diet. Another clue from this interview:

“My diet is very restricted right now, but Tara has been wonderful at helping me figure out what I can eat, like certain thick-skinned fruits and soy products,” says Anne Forgit, a leukemia patient and recent bone marrow transplant recipient.

Soy products. As readers of our book know, this is a highly toxic food.

Ms Mardigan does have a personal home page. The only clues I found there to her diet advice reside on her “Resources” page, where she recommends Michael Pollan’s In Defense of Food and  Dr. Walter Willett’s Eat, Drink, and Be Healthy. Pollan is a journalism professor who has made a career attacking industrial agriculture, and has likened the Atkins diet to an eating disorder. He seems to avoid specific diet advice, but it looks like he favors grains and omega-6-rich plant fats over animal fats. Dr. Willett is mentioned in our book, where we object to his opposition to coconut oil and saturated fat. He is a promoter of polyunsaturated fat and whole grain consumption.

If this is what Ms Mardigan is recommending to the Red Sox, it’s no wonder their bones are breaking:

  • Grains are toxic to bones. Wheat, oats, and other grains induce rickets, a softening of the bones that leads to frequent fractures. (This is discussed extensively in our book, and has been known since Mellanby’s original experimental investigations into rickets in dogs [1].)
  • Omega-6 polyunsaturated fats reduce bone mineral density. [2]

The Missing Nutrients

So the Red Sox players are being recommended a diet that is highly toxic to bones. But what about the key bone nutrients?  Are they lacking in those as well?

The answer is almost certainly yes. The fat-soluble nutrients are critical to bone remodeling, and it seems the Red Sox diet is completely lacking in vitamin K2.  Plant sources of vitamin K1 aren’t sufficient for bones, and animal sources of K2 seem to be excluded from the Red Sox diet.

Bone fracture rates are very strongly dependent on vitamin K2 levels. Most people are deficient, and supplementation with K2 reduces risk of vertebral fractures by 60%, hip fractures by 77%, and non-vertebral fractures by a remarkable 81%. [3]

If that happens on ordinary diets, the reduction in fracture rates would probably be even more remarkable on a K2-empty diet like the one that has been recommended to the Red Sox.

Conclusion

If a biomedical scientist were asked to contrive a diet that maximized the likelihood of bone fractures, the advice would be:

  1. Eat lots of grains to induce rickets.
  2. Eat vegetable oils and non-tropical fatty plants to reduce bone mineral density.
  3. Avoid animal and dairy fats to deprive the body of fat-soluble vitamins needed for bone mineralization, such as vitamin K2.
  4. Do not take nutritional supplements, in order to maintain a deficiency of bone nutrients.

It seems that this is precisely the advice that is being given to the Red Sox and their minor league players.

This year’s broken bones cost the Red Sox a chance at a World Series. The player who followed this diet advice most rigorously, Jacoby Ellsbury, lost a full season to bone fractures, and his injury history could cost him millions when he becomes a free agent next year.

As a lifelong Red Sox fan, I beseech the team to reconsider their diet advice.

References

[1] Mellanby E. (March 15 1919) An experimental investigation on rickets. The Lancet 193(4985):407-412. Reprinted in Nutrition. 1989 Mar-Apr; 5(2): 81-6; discussion 87. http://pmid.us/2520279.

[2] Watkins BA et al. Dietary ratio of n-6/n-3 PUFAs and docosahexaenoic acid: actions on bone mineral and serum biomarkers in ovariectomized rats. J Nutr Biochem. 2006 Apr;17(4):282-9. http://pmid.us/16102959. Watkins BA et al. Dietary ratio of (n-6)/(n-3) polyunsaturated fatty acids alters the fatty acid composition of bone compartments and biomarkers of bone formation in rats. J Nutr. 2000 Sep;130(9):2274-84. http://pmid.us/10958824.

[3] Cockayne S et al. Vitamin K and the prevention of fractures: systematic review and meta-analysis of randomized controlled trials. Arch Intern Med. 2006 Jun 26;166(12):1256-61. http://pmid.us/16801507.

Nutrients Are Needed to Heal Wounds and Injuries

Posted by on October 7, 2010 68 comments

Abby asked for suggestions to accelerate healing of her injuries. What should be done when a wound won’t heal?

More often than not, I think, slow healing wounds reflect nutritional deficiencies. Tissue regeneration is a nutrient-intensive process, and a lack of nutrients can radically slow it down.

Osteoporosis Epidemic Indicates a Widespread Deficiency of Bone Nutrients

Tissues are not static:  they are constantly broken down and regenerated. So just maintaining tissues requires a steady supply of nutrients.

Bone is particularly in need of certain nutrients: vitamins C, D, and K2; magnesium; and others. Unfortunately, the nutrients needed by bone are precisely the ones in which Americans are most deficient.

I believe that deficiencies in these nutrients are the main cause of the osteoporosis epidemic. Take vitamin K2. Most Americans are deficient in vitamin K2, which is needed for bone calcification. Non-vertebral fractures are five-fold more common in people with vitamin K2 deficiency. [1] The rise in fracture rate in women after menopause may be due to the fact that estrogen improves vitamin K2 status. [2]

Vitamin D is another nutrient critical for bone health. Bone mineral density peaks in the range 32 to 45 ng/ml. [3]

Vitamin C is a third nutrient necessary for bone health. Vitamin C is needed for collagen to form a meshwork that can then be mineralized by calcium, magnesium and other minerals. In the absence of vitamin C, bone is malformed.

Interestingly, cow’s milk has only one-fifth the vitamin C of human breast milk, and vitamin C is destroyed during pasteurization, so formula-fed babies before the days of vitamin C supplementation were prone to scurvy. Some believe that vitamin C and vitamin D deficiencies, not malicious parents, are responsible for “Shaken Baby Syndrome.” [4,5]

Vitamin Levels Determine the Success of Orthopedic Surgery

Today I read a press release about a study that found that 40% of all patients arriving for orthopedic surgery, and 52% of those coming in for trauma service, were deficient in vitamin D. Deficiency was defined as 25(OH)D levels below 20 ng/ml.

(We recommend keeping 25(OH)D between 35 and 50 ng/ml.)

What happened?  Those who had surgery with vitamin D deficiency failed to heal properly, while those who were vitamin D sufficient generally did well. Concluded the doctors:

“In the perfect world, test levels, fix and then operate,” said Joseph Lane, M.D., professor of Orthopedic Surgery and chief of the Metabolic Bone Disease Service at HSS, who led the study. “If you put people on 2,000-4,000 [milligrams] of vitamin D based on what their deficient value was, you can usually get them corrected in four to six weeks, which is when you are really going to need the vitamin D. If you are really aggressive right before surgery, you can correct deficient levels quickly, but you have to correct it, measure it, and then act on it.”

According to Dr. Lane, bone remodeling or bone tissue formation, a part of the healing process, occurs about two to four weeks after surgery. This is the critical stage when your body needs vitamin D….

“With arthroplasty, there is a certain number of patients that when you put in the prothesis, it breaks the bone adjacent to the protheses, which can really debilitate patients.” This could be prevented or minimized by rectifying vitamin D levels. Dr. Lane also explained that they now perform procedures where they grow a bone into a prosthesis without using cement. “In those people, it would be an advantage to have adequate vitamin D, because it matures the bone as it grows in, it is really healing into the prosthesis,” he said.

“The take home message is that low vitamin D has an implication in terms of muscle and fracture healing, it occurs in about 50 percent of people coming in for orthopedic surgery, and it is eminently correctable,” Dr. Lane said. “We recommend that people undergoing a procedure that involves the bone or the muscle should correct their vitamin D if they want to have an earlier faster, better, result. What we are saying is ‘wake up guys, smell the coffee; half of your patients have a problem, measure it, and if they are low, then fix it.'” [6]

Conclusion

If you have any sort of injury, make sure you are well nourished.

If an injury refuses to heal, consider it a red flag:  you are probably missing one or more crucial micronutrients. Take steps to identify the deficiencies and remedy them as quickly as possible.

References

[1] Cockayne S et al. Vitamin K and the prevention of fractures: systematic review and meta-analysis of randomized controlled trials. Arch Intern Med. 2006 Jun 26;166(12):1256-61. http://pmid.us/16801507

[2] Shea MK et al. Genetic and non-genetic correlates of vitamins K and D. Eur J Clin Nutr. 2009 Apr;63(4):458-64. http://pmid.us/18030310.

[3] 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. 2004 May 1;116(9):634-9. http://pmid.us/15093761.

[4] http://legaljustice4john.com/scurvySigns.htm.

[5] http://www.vitamindcouncil.org/newsletter/vitamin-d-deficiency-rickets-another-shattered-family.shtml.

[6] Hospital for Special Surgery (2010, October 7). Vitamin D deficiency rampant in patients undergoing orthopedic surgery, damaging patient recovery. ScienceDaily. October 7, 2010, http://www.sciencedaily.com/releases/2010/10/101006141556.htm.  Journal citation: L. Bogunovic, A. D. Kim, B. S. Beamer, J. Nguyen, J. M. Lane. Hypovitaminosis D in Patients Scheduled to Undergo Orthopaedic Surgery: A Single-Center Analysis. The Journal of Bone and Joint Surgery, 2010; 92 (13): 2300 DOI: 10.2106/JBJS.I.01231.

Why You Shouldn’t Supplement Calcium

Posted by on August 20, 2010 47 comments

Much of the advice handed out by medical doctors is unreliable.  One reason is that the research on which that advice is based is often conducted by specialists who overlook effects beyond their scope of professional interest.

We’ve mentioned previously the example of statin research. Statin studies are generally performed by cardiologists and in the U.S., many statin studies reported only heart attacks and other cardiovascular events as endpoints, not total mortality, cancer, or infectious disease. This method of evaluating drugs would show a lethal neurotoxin to be the best cardiac treatment ever:  In the neurotoxin group not a single patient would die of a heart attack!

A similar myopia has occurred in osteoporosis research, where doctors have focused on the effect of calcium supplements on bone density or fracture rates but often do not evaluate the effect of the supplements on overall health.

But other effects have to be considered, given that:

  • Calcification of coronary arteries may be the best single indicator of heart attack risk. [1]
  • In the Nurse’s Health Study, supplementation of calcium increased the risk of calcium oxalate kidney stones by 20%. [2]
  • Calcium is a strong promoter of biofilm formation in most pathogenic bacterial species. [3] It also likely promotes formation of Candida albicans (fungal) biofilms. As a result, it can aggravate bowel disorders and infectious diseases.

Clearly, calcium in the wrong places – a problem that could be exacerbated by calcium supplementation – is a major health risk.

What causes calcium to go in the wrong places? Deficiencies of vitamin D and vitamin K2 are common reasons. Deficiencies of both are widespread. Vitamin K2 deficiency is a known cause of vascular calcification.

A few years ago, a group of New Zealand researchers conducted a randomized clinical trial that found that over five years, older women taking calcium supplements doubled their risk of heart attack compared to women taking a placebo. [4]

Now, the same group has conducted a systematic review of calcium supplementation studies which confirms the link between calcium supplementation and heart attacks. Dr. Mark Bolland of the University of Auckland, New Zealand, and colleagues report that calcium supplementation increases the risk of heart attack by 31%, the risk of stroke by 20% and the risk of death by 9%. [5]

In an accompanying editorial, Dr. John Cleland writes:

Calcium supplements, given alone, … are ineffective in reducing the risk of fractures and might even increase risk, they might increase the risk of cardiovascular events, and they do not reduce mortality. They seem to be unnecessary in adults with an adequate diet. Given the uncertain benefits of calcium supplements, any level of risk is unwarranted. [6]

We concur. A healthy diet, including dairy and green leafy vegetables, not to mention a daily multivitamin (ours contains 200 mg calcium), should provide a sufficiency of calcium as long as vitamin D levels are normal. If you’re worried about bone health, supplement with vitamins D, K2, and magnesium citrate – not calcium.

[1] Budoff MJ et al. Long-term prognosis associated with coronary calcification: observations from a registry of 25,253 patients. J Am Coll Cardiol 2007;49:1860-1870. http://pmid.us/17481445. 

[2] Curhan GC et al. Comparison of dietary calcium with supplemental calcium and other nutrients as factors affecting the risk for kidney stones in women. Ann Intern Med. 1997 Apr 1;126(7):497-504. http://pmid.us/9092314.

[3] Kierek K, Watnick PI. The Vibrio cholerae O139 O-antigen polysaccharide is essential for Ca2+-dependent biofilm development in sea water. Proc Natl Acad Sci U S A. 2003 Nov 25;100(24):14357-62. http://pmid.us/14614140.  Geesey GG et al. Influence of calcium and other cations on surface adhesion of bacteria and diatoms: a review. Biofouling 2000; 15:195–205.

[4] Bolland MJ et al. Vascular events in healthy older women receiving calcium supplementation: randomised controlled trial. BMJ. 2008 Feb 2;336(7638):262-6. http://pmid.us/18198394.

[5] Bolland MJ et al. Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis. BMJ. 2010 Jul 29;341:c3691. doi: 10.1136/bmj.c3691. http://pmid.us/20671013.

[6] Cleland JG et al. Calcium supplements in people with osteoporosis. BMJ. 2010 Jul 29;341:c3856. http://pmid.us/20671014.