Nina Radford, MD, Director of Clinical Research and a cardiologist at Cooper Clinic, talks with Vitamin Expert Todd Whitthorne, about research reported in February 2013 by BMJ that calcium supplements are linked to significantly increased heart attack risk. Dr. Radford, board certified in Internal Medicine and Cardiovascular Disease, gives her opinions about calcium consumption (in both food and supplements) for women who are concerned about both bone health and heart health.
Below is a transcript from Todd Whitthorne’s interview with Dr. Robert Heaney, professor in the Department of Medicine at Creighton University in Omaha. Dr. Heaney has spent over 50 years in the study of osteoporosis, vitamin D, and calcium physiology; he’s authored three books and has published over 400 scientific papers, so when it comes to the world of vitamin D, and calcium in particular, Dr. Heaney is one of the leading gurus, literally, in the world! Click here to listen to the interview, or continue reading for the transcript.
This is Todd Whitthorne and I’m very pleased today to be joined once again by Dr. Robert Heaney, who is a professor in the Department of Medicine at Creighton University in Omaha. Dr. Heaney has spent over 50 years in the study of osteoporosis, vitamin D, and calcium physiology; he’s authored three books and has published over 400 scientific papers, so when it comes to the world of vitamin D, and calcium in particular, Dr. Heaney is one of the leading gurus, literally, in the world! So Dr. Heaney thanks again for joining us.
Robert Heaney, MD
It’s certainly a pet peeve of mine, and I know it is one of yours as well, and that’s primarily the media – how they love to focus on harm, or potential harm, as opposed to the overwhelming benefits of certain topics, and what I’m primarily referencing is the of the recent headlines from the US Preventive Services Task Force saying that postmenopausal women should avoid taking low daily doses of vitamin D and calcium to ward off bone fractures. They say that those amounts have no benefit for the primary prevention of fractures, but there is evidence that taking them could increase the likelihood of kidney stones. I know they released this last summer, and then it suddenly got another whole round of headlines, and I’m getting calls and e-mails with all sorts of questions about it and it drives me a little bit nuts! What about you?
Robert Heaney, MD
Well, yes, it was originally published in draft form in June of last year and that elicited a lot of media reaction because as you correctly point out the media love controversy, and if this seems to contradict the accepted wisdom then that’s considered newsworthy. However, it tends to get exaggerated. The current recommendations, which are essentially the same as the draft form nine months ago. The current recommendations are really quite confusing because they do recommend taking calcium and vitamin D for the prevention of falls in the elderly, but they don’t recommend it for the prevention of fractures. Well, so what’s a person to do? Well obviously what the person should do is continue to take calcium and vitamin D supplements.
What they mean when they say they don’t recommend is not saying you shouldn’t do this, it’s saying we don’t have the evidence to permit us to recommend this to you, and the kind of hidden subtext is “well it could be helpful, but we just don’t know.” Now in fact a lot of experts in the field feel they do know as a matter of fact…
I was going to say! What they know is not what you know, is it?
Robert Heaney, MD
Exactly, or right! And it’s worth pointing out that the Preventive Services Task Force consists of public health people, not one of whom, to my knowledge, and I recall I checked his last June, not one of them has ever published a scientific paper on calcium or vitamin D. I mean, they’re given a task, and the task is apply a certain set of rules to a set of published papers, and see if that constitutes evidence to make a formal recommendation, and if it doesn’t meet the standards of those rules, then they say “well, we can’t recommend.” But it’s very important that they’re not recommending against something, they’re simply saying they can’t recommend “for” it and there’s a big difference.
I understand. From a controversy standpoint, going back looking at PSA (Prostate-Specific Antigen Test) or mammograms, it’s not the first time that the US Preventive Services Task Force seems to be in conflict with a lot of the research world. But let me ask you in general, can calcium and vitamin D supplements increase the risk of kidney stones? What are your thoughts?
Robert Heaney, MD
No. No. No. I’m glad you asked that question. The truth is exactly the opposite. It’s been shown in good experimental studies, that increasing calcium intake decreases the risk of kidney stones. Now, I’m sure many people find it counterintuitive because kidney stones are made from calcium, and I must have too much calcium in my body and so I should cut down my calcium intake. Well, it’s been shown that if you do this you’ll double your risk of getting a recurrence of the kidney stone. There was a wonderful study from Italy published eight to ten years ago now published in the New England Journal of Medicine describing the results of precisely such a study, and they had a set of male kidney stone formers and half of them were put on a low calcium diet, and the other half were asked to increase their intake of calcium, cheese and stuff you know, and those who increased their intake had half the recurrences of those who restricted their intake, and that fits the biology. The reason for that, as we may have discussed previously Todd, is that one of the principal risk factors for kidney stones is a chemical compound called oxalic acid or oxalate, the salt form of oxalic acid, and some of that comes into us into our body through our diet, through food. Well, oxalate is a very potent stone former, it’s a more important stone former than calcium, and if you have a high calcium intake by mouth, much of that calcium stays in your intestinal tract and combines with oxalate in food and prevents the oxalate from being absorbed into your body, and therefore doesn’t have to be excreted to the kidney…, and therefore it’s not in the urine to predispose to kidney stone formation.
Robert Heaney, MD
There’s very good biology behind this, and lots of experimental data, and it does seem kind of counterintuitive, and many doctors don’t know what to tell you to do if you have kidney stones, so they say well you better cut out your milk or dairy or calcium supplements, or whatever the source may be. But that’s actually bad advice, and we have to try to counter that, so no, it does not cause kidney stones.
The reference there is a single paper that came out of the Women’s Health Initiative in which in the group receiving calcium and vitamin D supplements there was a seventeen percent increase in risk of kidney stones. Seventeen percent – not very big. But in fact if you look at the other segments of the Women’s Health Initiative Study, they had exactly the same kidney stone risk as this group that got the calcium and vitamin D supplements. So there really is no strong evidence there, and all the other evidence is in the other direction. It’s also worth noting that the vitamin D dose prescribed in the Women’s Health Initiative was only 400 IU (international units ) per day, and it’s worth noting that the compliance with the medication in the Women’s Health Initiative is only fifty percent.
Robert Heaney, MD
So that means on average, these people were getting only 200 IU (international units) of vitamin D – that’s not capable of doing anything, good or bad! That’s such a tiny dose, that it couldn’t possibly make any difference. But that’s the only evidence they had to go on. The point is that it was a big government study, and the US Public Services Task Force has these strong government connections so one talks to the other and they kind of feed off of one another. But the data points in exactly the opposite direction.
Well that’s very helpful, and you’re very clear in allowing us to understand exactly how that happens. One other headline Dr. Heaney, that I want to mention, and I’m sure many people have asked you about is the risk of calcium supplementation in terms of increasing the risk of heart attacks. What are your thoughts on that?
Robert Heaney, MD
Well, thank goodness that you don’t have to rely on my thoughts – that’s been clearly refuted in papers and major scientific journals in the last six months to twelve months, but mostly since last fall, and there’s always lag time because when those things came out, this was a group of New Zealand investigators who had seemingly found this kind of an effect in the study they did, and they’ve gone around the world with kind of an evangelistic fervor to tell people to be careful this could be making them worse by giving them heart attack. Well is a total re-analysis of big studies like the Women’s Health Initiative in this case, again, shows that this simply wasn’t true. It’s not just that it wasn’t found in the Women’s Health Initiative, but the New Zealand investigators had gone into the NIH database and had kind of cherry picked or preferentially selected some of the cases from the Women’s Health Initiative and used that to support their thesis. So, it was very important, therefore, that the people who had access to, and in a sense control of, the entirety of the data of the Women’s Health Initiative, repeat their analysis and they did, and they published that last fall and the answer is there’s nothing there.
That’s great news.
Robert Heaney, MD
So, the problem is that if you eat if you stopped taking calcium because of fear of a heart attack then the chances are you’ve increased your risk of a hip factor, and so more harm has been done. And I think it’s very important to say we all need more calcium and we all need more vitamin D and there are some ways to get that, but you mustn’t worry about an increased risk of heart attack because the evidence shows it’s not there. It’s not just that there isn’t any evidence to show it is there, it’s actually the opposite, it’s not there at all – there is no reason to believe that.
One more question Dr. Heaney. I know you’ve spent a great deal of your life studying these topics. The recommendations now seem to be at least 2000 IU of vitamin D per day is a pretty good starting point for most people. I know you have commented and lectured frequently about the dosage of 2600 IU reduce risk of falls and fractures, as well as other medical issues, but still, there is a huge variability between a three and six fold variance in terms of how we as individuals react to vitamin D. So what are your recommendations for both vitamin D and calcium for men and women?
Robert Heaney, MD
Well, I tend to swim against the stream a little bit here, and in this connection I should alert you to the fact that the US Preventive Services Task Force is once again looking at this vitamin D issue and raising the question of whether we should screen for vitamin D deficiency, and I’m quite sure that they’re going to come up with a “No, we shouldn’t.” I know the American Society of Clinical Pathologist, in trying to be good citizens, but I think bending over backwards, have identified five tests that physicians should think twice about ordering because, they, in their judgment, are probably not very helpful, and one of them is measuring vitamin D status…, and I think that’s wrong. But that’s all kind of preamble to the answer to your question. The only way to tell whether you’re getting enough vitamin D is by measuring. You have to measure what’s in the blood, because as you pointed out, the response to a given dose varies over six-fold range. We think that that’s because we think that that’s because different people have different capacities of the enzyme, probably mostly in their livers, that is responsible for converting vitamin D into the form that we measure in the blood stream, that is 25-hydroxyvitamin D. Some people are what I call very slow hydroxylaters, and others are every fast hydroxylaters, which means they have a lot of the enzyme necessary to do it, and in the other case means they don’t have much of the enzyme, so they don’t get as much for their vitamin D dose as somebody else does, and that means they need twice as much, or three times as much, or maybe even six times as much as the other person. We can’t tell that from looking at their forehead – there isn’t any UV or invisible ink on the backs of their hand you can scan with a UV lamp and see whether this person will need more or less. A good place to start, as you say, is at 2000 IU (international unit) per day, and once you’ve done that we like to measure them three to six months later. If they’re up in a good range, we stick with 2000 (IU); if they’re not then we double it until we get them where we want them. But you can’t tell that without measuring, so I’m strongly in favor measuring.
Okay. How about (recommendations) for calcium? Is there a difference between men and women? I know calcium is more challenging because there’s not a blood test for calcium like there is for vitamin D.
Robert Heaney, MD
There’s no way to assess calcium by a simple test. Vitamin D is really a wonderful nutrient in that regard as it permits measurement the status, and of the compound that the body is actually looking at and needs and uses. But we don’t have that for calcium as you correctly point out. Actually, this is a bit of a digression, but in all of these nutrient controversial areas, I take as my benchmark ancestral intake; that is, what did humans take before the agricultural revolution, surely before the Industrial Revolution, but before the agricultural revolution which was a giant change in the kinds of foods we ate. The natural vitamin D level under ancestral conditions would’ve been between 40 and 60 ng/ml. We know that because it is been measured in East African tribes that are following ancestral lifestyle, so I take as my benchmark, well I’m back in my blood level up to where it would have been had I been living under the more primitive circumstances.
Robert Heaney, MD
And the reason for that is that our physiology has been fine tuned to what the environment provided during the millions of years in which the human body was developing, and human physiology was evolving. Different animals have different requirements everything. For example, rats and mice are primarily nocturnal animals and therefore don’t get vitamin D from the sun in usual way. They have very low requirements and they metabolize vitamin D very differently. But we grew up in equatorial East Africa that’s how we developed, so we were getting sun every day of the year, and of course we didn’t wear clothing and didn’t have a lot of fur, so we got a lot of vitamin D. Now when it comes to calcium, the best guess is that we probably were getting from 1500 to 2500 mg of calcium per day, and again, I’d like to take that as my benchmark. Now that doesn’t have to come in, in the form of supplements, it’s probably better if it’s taken in as food, but the important thing is to get it in. The reason that it’s better as food is that with the decreased physical activity of the modern urbanized human, we can’t consume as much food as we did before, and many of the foods available to us are calcium poor, and micronutrient poor, and if we provide just the calcium in the form of the supplements then we’re not taking care of the other micronutrients that are probably deficient in the same individuals. So, I’m a strong advocate of natural food sources of calcium, but there’s definitely a role for supplements and that’s to be what their name says they are – supplements. But there’s a lot of sense to people take nutrients in and in the sense of taking medicine for a specific endpoint all nutrients are necessary for all body tissues, and it’s a mistake to think of a single end point because what with both calcium and vitamin D, I can name dozens of systems that are adversely affected by inadequate intake of either or both nutrients, so the goal is our bodies need these things, all of our organs, and all of our tissues need these things, and we should be focusing on this as nutrition, and not as medication.
Very Good. Well Dr. Heaney, I want to thank you for your time. I want to point out to our listeners that Dr. Heaney has several wonderful scientific presentations available on YouTube (http://www.youtube.com/). If you like to really dig deep and hear about some of Dr. Heaney’s research, and the things he’s been involvement there are three or four really good presentations available on YouTube. Continued success, and as always, I appreciate your time very much.
Robert Heaney, MD
Thank you very much.
Dr. Robert Heaney our guest today on our healthy living podcast. As always you can get more information at www.CooperAerobics.com
Todd Whitthorne interviews Jorn Dyerberg, MD, the father of the omega-3 movement. Dr. Dyerberg was studying the Eskimos, who ate a high fat diet, and had very low rates of heart disease, and discovered the protective effects of omega-3 fatty acids (EPA and DHA) in marine sources. Dr. Dyerberg talks about advances in the science of omega-3 fatty acids from 1970 to present day, and a bit about the 25,000 studies that have been conducted during this time period. Once studied primarily for cardiovascular health, researchers have also studied the impact of omega-3 fatty acids on inflammatory disorders, brain health, eye health, etc. Dr. Dyerberg discusses the protective effects of omega-3 fatty acids, and how much of the nutrients we need for optimal health.
Dr. Dyerberg is also the co-author (with Richard Passwater and Cheryl Hirsch) of the book The Missing Wellness Factors: EPA and DHA: The Most Important Nutrients Since Vitamins?
Click here to listen to the interview.
Laura DeFina, MD, from The Cooper Institute, is interviewed about research published this month in the Annals of Internal of Medicine. The study, shows that individuals who are fit at midlife have a lower risk of deveoping Alzheimer’s disease and other dementias in their Medicare years.
The study followed more than 19,000 generally healthy men and women who completed a preventive medical exam at Cooper Clinic in Dallas when they were, on average, 49 years of age. The exam also included an assessment of other health risk factors such as body mass index (BMI), blood pressure, and cholesterol. Their health status was evaluated using Medicare data between the years 1999 and 2009, an average of 24 years after their Cooper Clinic examination.
Listen to hear Dr. DeFina’s thoughts on the study.
Todd Whitthorne recently sat down with Dr. Nina Radford, and discussed HDL Cholesterol. Click here if you would prefer to listen to the interview.
Todd: Hello, and welcome to another Healthy Living podcast from Cooper Aerobics Center. This is Todd Whitthorne, and I’m joined today by Dr. Nina Radford the head of cardiology at the Cooper Clinic, and Dr. Radford we have a topic today that I think is going to interest a lot of our listeners. Generally when it comes to health, we like to distill things down to takeaways, and when it comes to cholesterol we have a tendency to think that LDL is lousy and the HDL is healthy. There’s a recent study published in May of 2012 in the Lancet that says, well maybe raising HDL is not all that beneficial. What do we need to know about that?
Dr. Radford: Well Todd, that’s a great question. Historically, when we talk about cholesterol parameters, as you described, we look at LDL, and when it’s high it’s bad for us – it increases the risk of heart attack…, and when we look at HDL, if it’s too low, it increases our risk of heart attack. And those are associations – if we look at a group of people who’ve had heart attacks versus a group of people who haven’t, and you find that high LDL is associated with heart attacks and low HDL is associated with heart attack, but that doesn’t necessarily prove causation.
Now with LDL cholesterol, there have been a number of studies that have gone on from “association” to proving “causation,” and how do we do that? Well first we say “Gosh, if high LDL is associated with heart attack, if we lower it with drugs does that lower the risk?”, and in fact there have been many, many studies showing if you lower LDL cholesterol with diet or medication, you reduce the risk of subsequent heart attacks.
They can also look at from another angle, and that is the genetic angle. There are some people who are actually born with genes that cause their LDL to be low. So, they look in those families who have those genes that cause low LDL, and they ask the question “In those families, is there a reduced risk of having a heart attack?”, and in fact there is. So, whether or not your LDL is low because you take medicine, or you follow specific lifestyles, or it’s low because low LDL happens to run in your family…, either way, both of those situations are associated with a lower risk of heart attack. So you make the transition from “association” to “cause.”
Now investigators are trying to do the same thing with HDL. So we say “Gosh, having a low HDL is associated with heart attacks – having a high HDL must be good for you then!” So we look at studies: If I give you a drug that causes your HDL to increase – something like niacin, for example, will that reduce the risk of having heart? And in fact, there was a recent trial called the Aim-High Trial that took patients who already had a low LDL (so that is they were already on medicine to lower their LDL because they have heart disease), but their HDL was low. Researchers treated patients with a drug that causes the HDL to go and see if it would lower their risk of having another heart event even more! The study did not demonstrate any benefit from increasing the HDL with the medication. So, then all of a sudden, people started to wonder if raising HDL is a good thing, “Is high HDL really protective?” because we didn’t see it in this study. So, what these investigators did in the Lancet study was they looked at people who have a genetic cause of having high HDL – they had genes that ran in their family that actually blessed them with very HDL levels.
Todd: Dr. Cooper calls that the Methuselah factor. I’ve heard him say that many times.
Dr. Radford: They’re just lucky they were born with a high HDL. Investigators looked at 21,000 people in one study and 12,000 people in another group, so they combined those groups and were looking at over 30,000 individuals who had this gene, and they predicted that the risk of having a heart attack should be lower in these people because they have HDL, and in fact they did not see that the risk was lower.
So here we have this Genetic Study, right on the heels of this Drug Trial, and all a sudden people are saying “Hey, I thought having a high HDL was good for you! What’s going on here?” Well, you have to be careful about dismissing decades of historical data based on a couple of studies.
For example, in this study where they gave a drug to increase the HDL to see if it would reduce risk, well we know that LDL, the bad cholesterol, is a bigger driver of risk than HDL. So if I lower your LDL and get it super low with a drug, plus you’re on an aspirin, and an ACE inhibitor, and fish oil, and you’re meditating, and you’re doing all the right things…, and on top of all those really good things, I add another good thing, it may be that the effect is not big enough that you can see it. Because you’re doing six other good things, and when you add the seventh the benefit isn’t big enough. And so, that may be part of.
But then when you look at this Genetics Study, and you add it to the Drug Study, what’s the story? Well, the story is this: It may be that having a high HDL is a marker for some other thing that you’re doing that’s good. So, for example, we know that if you want to increase your HDL and you exercise, you can do it. But what if exercise causes another thing to happen? So, and I’m going to make it up….. Let’s say exercise increases your “Todd” factor. So, if you’re a regular exerciser, your “Todd” factor goes sky high. Now, your HDL also goes sky high, and we can measure the HDL, but we don’t know how to measure the “Todd” factor.
Todd: At least not yet!
Dr. Radford: So, it may be that HDL is kind of going along for the ride and the real benefit of exercise is the “Todd” factor that we’re not smart enough to measure yet. So, that’s what we’re not clear about.
Now, should you stop doing things we know will raise HDL? Like being at your ideal body weight, taking some fish oil, exercising regularly? Absolutely not! But whether or not you should take medications to raise your HDL, beyond the other good heart healthy things that you’re doing, is not clear, and what most physicians are doing is taking it on a case-by-case basis.
If you’re taking a medication to raise your HDL don’t stop it, because we’ve only got that one Trial that’s raised some questions…, but it’s a good thing to ask your doctor when you see them next. You’re reviewing all your meds – it’s a good thing to do every year – and say you’re taking this for your blood pressure, taking this for cholesterol, this for prostate, this to make your hair shiny, etc. Every year you’ll want to look at all those meds and talk with your doctor and say “Do I need to take each of these (medications)?” And, if you happen to be on a drug for raising HDL, it’s a good time to review (taking it) and decide if you still need it.
Todd: So, where are we from your perspective – historically, it’s the question that comes up all the time – “Is at HDL? Is it LDL? Is it the combination, that atherogenic index, of total cholesterol divided by HDL?” Dr. Nina Radford, head of cardiology at the Cooper Clinic, what you think is the most important component? Or, is there a magic number we need to be thinking about, as the average patient?
Dr. Radford: Well, that is a great question! It depends a little bit on what your other risk factors are; what your age is; and what your gender is. So, for example, compared to men, HDL is probably a bigger driver of risk in women. But that has to do with probably differences in our hormones. LDL is still a driver of risk in women – it doesn’t mean you can willy-nilly have your LDL be high and super size your fries, but it looks like some studies suggest in women before they’re had their first heart attack or heart disease HDL is a big driver of risk.
In men, LDL appears to be a bigger driver. When you talk about patients who already had their first heart attack; had a stent; have heart disease…, LDL is a very big driver of risk, and needs to be very specifically controlled.
Todd: In both men and women?
Dr. Radford: Absolutely! In both genders! So it depends a little bit on the age and the clinical background in terms of which factors I’ll be more concerned about.
Todd: So the takeaway is case-by-case, patient-by-patient, one size does not fit all?
Dr. Radford: Absolutely.
Todd: Very good. Dr. Nina Radford, the head of cardiology at Cooper Clinic, great information as always! We appreciate your time Dr. Radford.
Folks, if you want more information, you can always sign up for the Get Cooperized Newsletter. We’ll have more podcasts in the very near future. Stay with us. We’ll see you soon.
Todd Whitthorne recently interviewed eye expert, Ophthalmologist Robert Able, Jr., MD. Dr. Abel is the author of The Eye Care Revolution and The DHA Story. In the interview Dr. Abel explains how nutrition and lifestyle impact our eye health. Click here to listen to the interview.
In the world of supplementation, mirtogenol, a combination of pycnogenol and bilberry, is discussed. Pycnogenol is French maritime pine bark, that’s like a powerful vitamin C, and it’s extremely helpful in diabetics and protecting the cross-linking of their blood vessels. In glaucoma patients, pycnogenol helps protect the nerve fibers. Bilberry helps peripheral vision and night vision. Mirtogenol helps lower intraocular pressure.
Dr. Abel also discusses an herbal blend called Ifolia, and how it may positively impact glaucoma by reducing intraocular pressure.
There’s a new Optical Coherence Tomography (OCT) device that uses optical imaging to assist in diagnosing physiologic and pathologic conditions of the eye. The scanner is hand-held, so can be used in all patients, and comes with interchangeable lenses that allow various parts of the eye, from cornea to retina, to be examined. Using the device and looking at the eye, there’s the potential to detect early stage Alzheimer’s, and Parkinson’s. The device is also used for MS detection too, as the thickness of the retina is changed in individuals who have MS. Dr. Abel says retinal testing may also pick up depression, because the eye and brain are so intimately connected.
Our eyes need at least five hours of darkness every day (or night) in order to rest and replenish. Sleep is needed mechanically and functionally. Stroke, increased glaucoma risk, cornea warping, and stroke in the eye, the sudden loss of vision that can occur during sleep, are all discussed.
Dr. Abel identifies the primarily culprits that make our vision worse – they include explosure to Ultra-Violet (UV) light; poor dietary choices; poor lifestyle choices; and stress.
Sunglasses aren’t just for fashion. Dr. Abel make recommendations on what kind of glasses to select.
Finally, Dr. Abel discusses eye exams, and make recommendations for how often each of us should make an appointment to get our eyes checked.
In addition to his traditional books on eye health, Dr. Abel has written two thrillers, Lethal Hindsight, and Last Sighting. He is also the author of Lumi’s Book of Eyes, a book for children about eye health. The book has QR (Quick Response) codes sprinkled throughout it, with each one teaching a different lesson.