Hi Sharon. This will be the opposite of a quick boost reply!
To quote the relevant parts of the 2 UpToDate articles - first Vitamin D and then calcium:
1) Vitamin D Adverse effects — The first measurable consequences of vitamin D toxicity are hypercalciuria and hypercalcemia, which have been observed only at 25(OH)D levels above 88 ng/mL...
Excessive vitamin D, especially combined with calcium supplementation, may cause hypercalcemia, hypercalciuria, and kidney stones. In addition, chronically high levels of 25(OH)D (exceeding 40 and 50 ng/mL [100 and 125 nmol/L], respectively) have been found in some association studies to be linked to a modest increase in risk of some cancers (eg, pancreatic), mortality, and falls. More studies are needed to define the upper level of serum 25(OH)D that is safe, not only in respect to the risk of kidney stones, but also for falls and chronic diseases.
2) Calcium side effects — The total intake of calcium (diet plus supplements) should not routinely exceed 2000 mg/day, because of the possibility of adverse effects [6].
Nephrolithiasis — In general, concern that high dietary calcium increases the risk of nephrolithiasis in otherwise healthy patients is unfounded as the incidence of stone formation appears to be reduced in both females and males [23,24]. In randomized, clinical trials, however, calcium supplements have been associated with an increased risk of kidney stones [23]. The Women's Health Initiative (WHI) trial reported an increased risk of kidney stones in postmenopausal women who were supplemented with calcium and vitamin D when compared with placebo [25]. This issue is discussed in detail separately. (See "Kidney stones in adults: Epidemiology and risk factors", section on 'Calcium'.)
Cardiovascular disease — The effect of calcium supplementation on risk of cardiovascular disease (CVD), particularly myocardial infarction (MI), is controversial [26-31]. However, neither calcium supplements (up to 1000 mg daily), increased dietary intake of calcium, nor vitamin D supplements have been shown to increase all-cause [32] or cardiovascular [33] mortality, and in one meta-analysis of trials comparing vitamin D with or without calcium with no treatment or placebo, calcium plus vitamin D was associated with reduced all-cause mortality in older adults (hazard ratio [HR] 0.91, 95% CI 0.84-0.98) [34]. We and others [35] suggest combined calcium and vitamin D supplementation, as reviewed above. The National Osteoporosis Foundation considers supplementation in this dose range safe from a cardiovascular viewpoint [35]. (See 'Optimal intake' above.)
In the WHI trial, there was no effect of calcium and vitamin D supplementation on CVD [26]. In this trial, 36,282 postmenopausal women ages 50 to 69 years were randomly assigned to calcium (1000 mg/day) plus vitamin D (400 international units/day) or placebo (personal supplementation of up to 1000 mg additional calcium and 600 international units vitamin D was also allowed) [25]. CVD was a prespecified secondary outcome [26]. At baseline, mean calcium intake (diet plus supplements) was approximately 1150 mg/day, and 54 percent of participants were taking nonprotocol calcium supplements. After seven years, calcium plus vitamin D supplementation had no significant effect on the incidence of MI (confirmed in 411 and 390 women assigned to calcium/vitamin D and placebo, respectively; HR 1.05, 95% CI 0.91-1.20) or stroke (362 versus 377 strokes; HR 0.95, 95% CI 0.82-1.10).
However, the findings of two meta-analyses evaluating calcium or calcium with or without vitamin D supplementation (eight and nine trials, respectively) raised some concern about an increased risk of MI in patients randomly assigned to calcium versus placebo (166 versus 130 MIs; pooled relative risk [RR] 1.27, 95% CI 1.01-1.59) or calcium with or without vitamin D versus placebo (374 versus 302 MIs; RR 1.24, 95% CI 1.07-1.45) [27,28]. The meta-analyses had several limitations. The trials in the meta-analyses were not designed to explore cardiovascular outcomes, which were not uniformly collected or adjudicated. Patient-level data were not available from all the trials. In one of the meta-analyses, only data from a subgroup of participants in the WHI (those not taking personal calcium supplements at randomization), rather than all participants, were included in the analysis [28]. The baseline dietary calcium intake in the trials ranged from 750 to 1240 mg daily, and the addition of calcium supplements raised total intake over 1500 to 2000 mg daily in many patients, which is higher than recommended.
In contrast, other meta-analyses have not shown an increased risk of cardiovascular events with calcium with or without vitamin D supplementation [29,33,36]. As an example, in a pooled analysis of four trials, calcium supplementation did not significantly increase the risk of CVD events compared with placebo (RR 1.14, 95% CI 0.92-1.41). In these trials, dietary intake of calcium ranged from 800 to 900 mg daily, and the dose of calcium supplements ranged from 600 to 1200 mg daily. In a pooled analysis of two trials (one of which was the WHI and included data from all participants), combined vitamin D and calcium supplementation versus double placebos (RR 1.04, 95% CI 0.92-1.18) and vitamin D alone compared with placebo (RR 0.90, 95% CI 0.77-1.05) also did not significantly increase the risk of CVD, and there was a suggestion of a benefit in CVD reduction with vitamin D alone. As in the meta-analyses described above, none of the trials were designed to assess the effects of calcium or vitamin D on cardiovascular outcomes.
In some [37,38], but not all [39-41], prospective studies, there was an increased risk of cardiovascular problems with calcium supplements. As examples:
●One prospective study showed a significant increased risk of MI in users versus nonusers of calcium supplements (HR 1.86, 95% CI 1.17-2.96) [37], and the other showed an increased risk of heart disease death among men, but not women, who used calcium supplements (>1000 mg daily) versus men who did not take supplements (RR 1.19, 95% CI 1.03-1.37) [38]. There were only 20 to 60 events in the calcium group, which reduced the precision of the analyses [37,38].
●A very large prospective cohort study from the United Kingdom did not show evidence of an association in females or males between use of calcium and/or vitamin D supplements and hospitalization for MI or ischemic heart disease, or death after an ischemic cardiovascular event [41]. The HR for admission with MI was 0.97 (95% CI 0.79-1.2) for females taking calcium supplementation and 1.16 (95% CI 0.92-1.46) for males. There were many more events in this study compared with prior prospective studies (eg, 929 females and 2456 males were admitted with MI).
In contrast to the concern raised with calcium supplements, prospective cohort studies have shown either no relationship [38,39] or an inverse relationship [37,42] between dietary calcium intake and risk of heart disease death or MI. As an example, in one study (23,980 participants with mean follow-up of 11 years), there was a significant reduction in MI risk in patients with higher versus lower total dietary calcium intake (HR 0.69, 95% CI 0.50-0.94 for the third compared with lowest quartile of total dietary calcium intake) [37]. Thus, it is unclear from the present data whether intake of dietary calcium versus calcium supplements confers different cardiovascular risks. Randomized trials of calcium and vitamin D supplementation with CVD events ascertained as a primary endpoint are required to determine if calcium supplementation is associated with an increased occurrence of these events [43].
Other — Other potential side effects of high calcium intake include dyspepsia and constipation. In addition, calcium supplements interfere with the absorption of iron and thyroid hormone, and therefore, these medications should be taken at different times.
Based on the literature at the time in 2015 (including a meta-analysis (Bolland MJ, Avenell A, Baron JA, Grey A, MacLennan GS, Gamble GD, et al. Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis. BMJ 2010;341:c3691) of cardiovascular events in randomized, placebo controlled trials of calcium supplements (without vitamin D co-administration I wrote a post (https://theskepticalcardiologist.com/2015/02/21/calcium-supplements-would-you-rather-have-a-hip-fracture-or-a-heart-attack/) that warned my patients that calcium supplements significantly increased the risk of myocardial infarction by 31% in five trials involving 8151 participants.
I felt that patients should be informed of the increased MI risk and balance that versus any reduced fracture risk.
My gestalt of the literature since then is that vitamin D and Calcium don't do much for fracture reduction and I tell most of my patients to stop calcium supplements.
I trust your judgement and sources quoted here, this is really helpful! And I agree that the benefit of supplementation is pretty underwhelming. Thank you for adding the link to your post and I will read later for sure.
Skim and low-fat yogurt and cheese are not unhealthy per se. But they are created by an industrial processing step to remove dairy fats which have been inappropriately lumped in with fats from beef. Typically to make the yogurt palatable , it is then adulterated with added sugar components that are unhealthy.
Here's my summary of the evidence on dairy fat and CV disease circa 2014 (https://theskepticalcardiologist.com/dairy-fat-and-heart-disease/). Since then a growing body of authorities in the field now recognize that the saturated fat in dairy should not be vilified.
Saturated fat is not a monolithic villain but a family with short chain , medium chain and long chain members all of which have different properties and are consumed in a food millieu not by themselves.
Just FYI, the yogurt I eat is Stonyfield organic nonfat plain yogurt. It has 7g of sugar, none of which are added sugars.
Its ingredients are certified pasteurized organic nonfat milk, pectin, and Vitamin D3.
It has 6 live action cultures: S. thermophilus, L. bulgaricus, L. acidophilus, bifidus, l. paracasei and L. rhamnosus.
I have generally avoided red meat for many years, but since the JACC study you linked to indicates, "meat is a major source of protein, bioavailable iron, minerals, and vitamins. In modest amounts, unprocessed red meat constitutes an important part of the diet for the elderly and low-income populations in many developing countries," I may just go out and buy a filet mignon! (I'm 81 years old. I also eat dark chocolate every day. Some of my fat intake comes from a daily tablespoon of chopped unsalted walnuts.)
Great points and I recall reading this post you wrote a while back. The saturated fat category is not monolithic, and I also agree that full fat dairy in moderation has been shown to be OK in terms of CV risk. Counterintuitive, but the low fat mantra really opened the door to high carbohydrate intake and higher glycemic indices and consequent obesity.
A folksy way of illustrating this would be to look at the pictures of grandparents and great-grandparents who ate butter, lard, whole milk etc, were physically active if not exercisers, and had much less abundant candy/desserts/etc. Mostly thin as rails, right? An oversimplification, I know.
Headed out for a run now, then going to have hot chocolate with full fat whole milk, maybe non-homogenized, with daughter for a belated Valentine's treat. The sugar is the worst part of that plan. Have a great weekend, and thanks for your contributions to the comments!
Excellent! I've just started liking Lion's Mane mushrooms, roasted in the oven. Have you tried these? Apparently good for neurologic health, too, as they have some neurotrophic properties. Will do a post on that someday and sound like a quack, but mostly I just really like the umame ;)
Not sure how to tell if mushrooms being sold have been exposed to UV light for them to start making Vit D... will check labels but probably in the dark here. Sorry. About the pun.
After my bone density test came back recently pushing me into Osteoporosis on the femoral neck bone only slightly increased, my GYN ran a bunch of tests before going on any drugs. The other 2 areas are still in Osteopenia.
My parathyroid test came back on the high side. She recommended to see an ENDO. He recommended to take a high dose (50,000 iu) of Vit. D (was deficient) for 3 months once a week, followed by 2000 iu Vit. D each day for the next 3 months and have blood work done.
Have an appointment in March to see how this worked. Been taking 1000 iu each day for years, but older now, get less sun living in the NE so perhaps the issue will be cleared up with more Vit. D daily.
Thanks for sharing this case report... makes sense. The hyperparathyroidism can be primary (overactive gland) or secondary (such as reaction to Vitamin D deficiency and consequent calcium deficit). Good to see endocrine for this I agree, and hopefully all will be corrected by the time of the next blood draw!
P.S. I think "pseudopseudohypoparathryoidism" is one of the longest words in the medical dictionary, just in case you want to sound impressive at a dinner party.
Nice work but you need to work on your handwriting, too legible for a doctor.
If one does decide to supplement for whatever reason, they should look at this site I mentioned in a few of my posts. https://www.opss.org/
I do take multivitamins but within RDA. In my old age, I am discovering the wonderful world of senescence. Taking into account the many metabolic changes such as digestion, seems a logical approach. However, anyone looking into this should avoid the weeds (as I pointed out before - many things like to bite you). The multibillion supplement industrial complex like to paint a "anti-aging" picture.
Thanks KB, and I will try harder to write sloppily next time, thanks for the credibility reminder ;)
Great links provided, and I appreciate and agree with your approach to "senescence." It really is the word of the moment, and Eric Topol has been highlighting some of the research coming out about senescent cells causing chain reaction senescence down the line. I'm sure you've read that too!
Dr. McCormick, you are a hero for sorting through all this to make it clear! I have to say, I long ago gave up on figuring this out. For one, it seems to be a moving target. For another, it’s a bona fide drag to have to count up units on everything you eat. I do take D3 1000, as I am persuaded it’s impossible to get what you need from food alone, but for calcium I remain in “stay out of the pill box” mode, rely on food, and hope it’s enough. Re the dairy, while I try to stay low fat where I can, I appreciate the Skeptical Cardiologist’s comment that full fat dairy isn’t a concern for increased cardiovascular risk. On that note, for lunch today, I am going to indulge in melted cheese and tomatoes on Orwasher’s Cabernet Rustica bread (really delicious bread, BTW—you can buy a loaf sliced and frozen, so for small households, it doesn’t go to waste).😎
Man, if you heard a stomach growl a couple seconds ago that was me after reading the "melted cheese and tomatoes on Orwasher’s Cabernet Rustica bread." Seriously my stomach is rolling around and insisting I feed it now! I also highly appreciate when cardiologists validate what I have been reading over the past 5-10 years about dietary fat, and even saturated dairy fat, not being the smoking guns of CV disease. "Everything in moderation" keeps winning the day, and your approach to calcium/D sounds low tech and perfect.
Thanks for this! I WISH I could meet you in the dairy aisle! I’m dairy-free due to Alpha-gal, but will check my nondairy “milk” for its added benefits.
Hi Donna - Alpha-gal is such a hard one to adjust to, presumably from a Lone Star Tick Bite perhaps? No need to answer, but I have a few people in my practice with this now. Let's meet in the organic fruit and vegetable section then... Have a good weekend!
Thanks Marty! I'm going to let this subject go now and just remember the bottom line numbers and goals... now where did I put those yellow sticky notes?!
I LOVE this post and (the post-its). I eat yogurt, leafy greens and cheese every day but I still think I’m falling short. I just wish I could down a glass of milk but I find it so unpalatable, almost mucus-like. I am allergic to most nuts and find soy milk even more unpleasant. Can anyone give me suggestions of how to best disguise milk so that I can just get it down, shot glass style? Add chocolate? Blend with a banana and freeze and make a “fake” ice cream? Asking seriously! 😂
Hi Lindsey, and thanks for the humor! Our daughter has a tree nut allergy, so I understand how vigilant you must be all the time with food. I don't like soy/oat/other "milks" either, but I do like non-homogenized whole milk (they sell at whole foods), with a slick of "butter" on top that you have to stir in yourself. Makes amazing hot chocolate, but obviously too much sugar for a regular source. I like your idea of sneaking some milk into smoothies. ChatGPT came up with this pretty classic one just now:
Ingredients:
1 cup whole milk
1 ripe banana, sliced
1/2 cup frozen berries (such as strawberries, blueberries, or raspberries)
1 tablespoon honey or maple syrup (optional, for sweetness)
1/2 cup Greek yogurt (optional, for added creaminess and protein)
1 tablespoon chia seeds or flaxseeds (optional, for extra nutrients)
Handful of spinach or kale (optional, for added greens)
Personalization factors for Vitamin D treatment include:
Body size: less for youths, more for obese
Have genes that reduce Vitamin D blood level (which can be measured)
Have genes that restrict the amount getting to cells
Measurement of PTH may be a proxy for Vitamin D level in cells
One of the genes, that deactivates the Vitamin D Receptor, can be activated 16+ ways
Have a disease associated with Low Vitamin D
Have a disease that consumes a lot of Vitamin D
Have a disease that is associated with poor Vitamin D response (Asthma, etc.)
Have a disease that can only be fought by high levels of Vitamin D (such as MS, psoriasis)
Have a disease that deactivates the Vitamin D Receptor (COVID, Breast Cancer, etc)
Have a poor gut – which decreases bio-absorption of Vitamin D (May need a gut-friendly form)
Have had gal bladder removed – which decreases absorption of fat-soluble Vitamins
Smoking
Taking drugs that reduce Vitamin D
Having a medical procedure that decreases Vitamin D level (Dialysis, surgery, etc.)
Have a disease that is associated with low Vitamin D (Diabetes, etc.)
Have a disease that is associated with a poor Vitamin D response (Asthma, etc.)
Unable to or dislikes swallowing pills (powder, liquid, spray, and topical forms are available)
Was born preterm or mother had low vitamin D while pregnant
increases risk of many Vitamin D diseases up to 50 years later
Have diseases that run in the family that are associated with low Vitamin D
Have little ability to get Vitamin D from the noonday sun
Concealing clothes, far from the equator, dark skin, avoiding the very hot sun,
shift worker, nursing home, wheelchair
Are in a very stressful situation
Have poor liver or kidney (needed to metabolize vitamin D in the bloodstream)
Have a poor lymph system (required to get Vitamin D in the intestine into the blood)
Loading dose if signs of improvement are needed in a month instead of within a fraction of a year
The above are all documented in VitaminDWiki - Solutions include:
different dose, different form, UV lamp, cofactors, non-daily dose
Hope to have an interactive service on VitaminDWiki before the end of 2024 which will allow visitors to quickly and easily get personalized Vitamin D recommendations
Thank you Ryan. I do Calcium and D suppliments I may overdose is this possible and if so the results?
Hi Sharon. This will be the opposite of a quick boost reply!
To quote the relevant parts of the 2 UpToDate articles - first Vitamin D and then calcium:
1) Vitamin D Adverse effects — The first measurable consequences of vitamin D toxicity are hypercalciuria and hypercalcemia, which have been observed only at 25(OH)D levels above 88 ng/mL...
Excessive vitamin D, especially combined with calcium supplementation, may cause hypercalcemia, hypercalciuria, and kidney stones. In addition, chronically high levels of 25(OH)D (exceeding 40 and 50 ng/mL [100 and 125 nmol/L], respectively) have been found in some association studies to be linked to a modest increase in risk of some cancers (eg, pancreatic), mortality, and falls. More studies are needed to define the upper level of serum 25(OH)D that is safe, not only in respect to the risk of kidney stones, but also for falls and chronic diseases.
2) Calcium side effects — The total intake of calcium (diet plus supplements) should not routinely exceed 2000 mg/day, because of the possibility of adverse effects [6].
Nephrolithiasis — In general, concern that high dietary calcium increases the risk of nephrolithiasis in otherwise healthy patients is unfounded as the incidence of stone formation appears to be reduced in both females and males [23,24]. In randomized, clinical trials, however, calcium supplements have been associated with an increased risk of kidney stones [23]. The Women's Health Initiative (WHI) trial reported an increased risk of kidney stones in postmenopausal women who were supplemented with calcium and vitamin D when compared with placebo [25]. This issue is discussed in detail separately. (See "Kidney stones in adults: Epidemiology and risk factors", section on 'Calcium'.)
Cardiovascular disease — The effect of calcium supplementation on risk of cardiovascular disease (CVD), particularly myocardial infarction (MI), is controversial [26-31]. However, neither calcium supplements (up to 1000 mg daily), increased dietary intake of calcium, nor vitamin D supplements have been shown to increase all-cause [32] or cardiovascular [33] mortality, and in one meta-analysis of trials comparing vitamin D with or without calcium with no treatment or placebo, calcium plus vitamin D was associated with reduced all-cause mortality in older adults (hazard ratio [HR] 0.91, 95% CI 0.84-0.98) [34]. We and others [35] suggest combined calcium and vitamin D supplementation, as reviewed above. The National Osteoporosis Foundation considers supplementation in this dose range safe from a cardiovascular viewpoint [35]. (See 'Optimal intake' above.)
In the WHI trial, there was no effect of calcium and vitamin D supplementation on CVD [26]. In this trial, 36,282 postmenopausal women ages 50 to 69 years were randomly assigned to calcium (1000 mg/day) plus vitamin D (400 international units/day) or placebo (personal supplementation of up to 1000 mg additional calcium and 600 international units vitamin D was also allowed) [25]. CVD was a prespecified secondary outcome [26]. At baseline, mean calcium intake (diet plus supplements) was approximately 1150 mg/day, and 54 percent of participants were taking nonprotocol calcium supplements. After seven years, calcium plus vitamin D supplementation had no significant effect on the incidence of MI (confirmed in 411 and 390 women assigned to calcium/vitamin D and placebo, respectively; HR 1.05, 95% CI 0.91-1.20) or stroke (362 versus 377 strokes; HR 0.95, 95% CI 0.82-1.10).
However, the findings of two meta-analyses evaluating calcium or calcium with or without vitamin D supplementation (eight and nine trials, respectively) raised some concern about an increased risk of MI in patients randomly assigned to calcium versus placebo (166 versus 130 MIs; pooled relative risk [RR] 1.27, 95% CI 1.01-1.59) or calcium with or without vitamin D versus placebo (374 versus 302 MIs; RR 1.24, 95% CI 1.07-1.45) [27,28]. The meta-analyses had several limitations. The trials in the meta-analyses were not designed to explore cardiovascular outcomes, which were not uniformly collected or adjudicated. Patient-level data were not available from all the trials. In one of the meta-analyses, only data from a subgroup of participants in the WHI (those not taking personal calcium supplements at randomization), rather than all participants, were included in the analysis [28]. The baseline dietary calcium intake in the trials ranged from 750 to 1240 mg daily, and the addition of calcium supplements raised total intake over 1500 to 2000 mg daily in many patients, which is higher than recommended.
In contrast, other meta-analyses have not shown an increased risk of cardiovascular events with calcium with or without vitamin D supplementation [29,33,36]. As an example, in a pooled analysis of four trials, calcium supplementation did not significantly increase the risk of CVD events compared with placebo (RR 1.14, 95% CI 0.92-1.41). In these trials, dietary intake of calcium ranged from 800 to 900 mg daily, and the dose of calcium supplements ranged from 600 to 1200 mg daily. In a pooled analysis of two trials (one of which was the WHI and included data from all participants), combined vitamin D and calcium supplementation versus double placebos (RR 1.04, 95% CI 0.92-1.18) and vitamin D alone compared with placebo (RR 0.90, 95% CI 0.77-1.05) also did not significantly increase the risk of CVD, and there was a suggestion of a benefit in CVD reduction with vitamin D alone. As in the meta-analyses described above, none of the trials were designed to assess the effects of calcium or vitamin D on cardiovascular outcomes.
In some [37,38], but not all [39-41], prospective studies, there was an increased risk of cardiovascular problems with calcium supplements. As examples:
●One prospective study showed a significant increased risk of MI in users versus nonusers of calcium supplements (HR 1.86, 95% CI 1.17-2.96) [37], and the other showed an increased risk of heart disease death among men, but not women, who used calcium supplements (>1000 mg daily) versus men who did not take supplements (RR 1.19, 95% CI 1.03-1.37) [38]. There were only 20 to 60 events in the calcium group, which reduced the precision of the analyses [37,38].
●A very large prospective cohort study from the United Kingdom did not show evidence of an association in females or males between use of calcium and/or vitamin D supplements and hospitalization for MI or ischemic heart disease, or death after an ischemic cardiovascular event [41]. The HR for admission with MI was 0.97 (95% CI 0.79-1.2) for females taking calcium supplementation and 1.16 (95% CI 0.92-1.46) for males. There were many more events in this study compared with prior prospective studies (eg, 929 females and 2456 males were admitted with MI).
In contrast to the concern raised with calcium supplements, prospective cohort studies have shown either no relationship [38,39] or an inverse relationship [37,42] between dietary calcium intake and risk of heart disease death or MI. As an example, in one study (23,980 participants with mean follow-up of 11 years), there was a significant reduction in MI risk in patients with higher versus lower total dietary calcium intake (HR 0.69, 95% CI 0.50-0.94 for the third compared with lowest quartile of total dietary calcium intake) [37]. Thus, it is unclear from the present data whether intake of dietary calcium versus calcium supplements confers different cardiovascular risks. Randomized trials of calcium and vitamin D supplementation with CVD events ascertained as a primary endpoint are required to determine if calcium supplementation is associated with an increased occurrence of these events [43].
Other — Other potential side effects of high calcium intake include dyspepsia and constipation. In addition, calcium supplements interfere with the absorption of iron and thyroid hormone, and therefore, these medications should be taken at different times.
Based on the literature at the time in 2015 (including a meta-analysis (Bolland MJ, Avenell A, Baron JA, Grey A, MacLennan GS, Gamble GD, et al. Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis. BMJ 2010;341:c3691) of cardiovascular events in randomized, placebo controlled trials of calcium supplements (without vitamin D co-administration I wrote a post (https://theskepticalcardiologist.com/2015/02/21/calcium-supplements-would-you-rather-have-a-hip-fracture-or-a-heart-attack/) that warned my patients that calcium supplements significantly increased the risk of myocardial infarction by 31% in five trials involving 8151 participants.
I felt that patients should be informed of the increased MI risk and balance that versus any reduced fracture risk.
My gestalt of the literature since then is that vitamin D and Calcium don't do much for fracture reduction and I tell most of my patients to stop calcium supplements.
Dr P
I trust your judgement and sources quoted here, this is really helpful! And I agree that the benefit of supplementation is pretty underwhelming. Thank you for adding the link to your post and I will read later for sure.
Dr. P,
Are you in the article suggesting that plain non-fat yogurt (and non-fat cottage cheese) and reduced-fat cheese are NOT heart healthy?
Skim and low-fat yogurt and cheese are not unhealthy per se. But they are created by an industrial processing step to remove dairy fats which have been inappropriately lumped in with fats from beef. Typically to make the yogurt palatable , it is then adulterated with added sugar components that are unhealthy.
Here's my summary of the evidence on dairy fat and CV disease circa 2014 (https://theskepticalcardiologist.com/dairy-fat-and-heart-disease/). Since then a growing body of authorities in the field now recognize that the saturated fat in dairy should not be vilified.
Saturated fat is not a monolithic villain but a family with short chain , medium chain and long chain members all of which have different properties and are consumed in a food millieu not by themselves.
(https://www.jacc.org/doi/10.1016/j.jacc.2020.05.077)
Dr P
Thanks for taking the time to reply, Dr. P.
Just FYI, the yogurt I eat is Stonyfield organic nonfat plain yogurt. It has 7g of sugar, none of which are added sugars.
Its ingredients are certified pasteurized organic nonfat milk, pectin, and Vitamin D3.
It has 6 live action cultures: S. thermophilus, L. bulgaricus, L. acidophilus, bifidus, l. paracasei and L. rhamnosus.
I have generally avoided red meat for many years, but since the JACC study you linked to indicates, "meat is a major source of protein, bioavailable iron, minerals, and vitamins. In modest amounts, unprocessed red meat constitutes an important part of the diet for the elderly and low-income populations in many developing countries," I may just go out and buy a filet mignon! (I'm 81 years old. I also eat dark chocolate every day. Some of my fat intake comes from a daily tablespoon of chopped unsalted walnuts.)
;-)
Also, your readers should no that they can consume full fat dairy without any concern about increasing cardiovascular risk :)
Great points and I recall reading this post you wrote a while back. The saturated fat category is not monolithic, and I also agree that full fat dairy in moderation has been shown to be OK in terms of CV risk. Counterintuitive, but the low fat mantra really opened the door to high carbohydrate intake and higher glycemic indices and consequent obesity.
A folksy way of illustrating this would be to look at the pictures of grandparents and great-grandparents who ate butter, lard, whole milk etc, were physically active if not exercisers, and had much less abundant candy/desserts/etc. Mostly thin as rails, right? An oversimplification, I know.
Headed out for a run now, then going to have hot chocolate with full fat whole milk, maybe non-homogenized, with daughter for a belated Valentine's treat. The sugar is the worst part of that plan. Have a great weekend, and thanks for your contributions to the comments!
I’ll see you in the mushroom isle, 900 units for 3 oz looks fantastic to me and mushrooms are so delicious😃
Excellent! I've just started liking Lion's Mane mushrooms, roasted in the oven. Have you tried these? Apparently good for neurologic health, too, as they have some neurotrophic properties. Will do a post on that someday and sound like a quack, but mostly I just really like the umame ;)
Not sure how to tell if mushrooms being sold have been exposed to UV light for them to start making Vit D... will check labels but probably in the dark here. Sorry. About the pun.
We love lion’s mane mushrooms. I did some googling and found that Monterey Mushroom Company gives their mushrooms the UV treatment.
California (Monterey), for the win, as usual! We have Kennett Square as a mushroom producing hub, so I'll do a little investigation on that, too.
After my bone density test came back recently pushing me into Osteoporosis on the femoral neck bone only slightly increased, my GYN ran a bunch of tests before going on any drugs. The other 2 areas are still in Osteopenia.
My parathyroid test came back on the high side. She recommended to see an ENDO. He recommended to take a high dose (50,000 iu) of Vit. D (was deficient) for 3 months once a week, followed by 2000 iu Vit. D each day for the next 3 months and have blood work done.
Have an appointment in March to see how this worked. Been taking 1000 iu each day for years, but older now, get less sun living in the NE so perhaps the issue will be cleared up with more Vit. D daily.
Thanks for sharing this case report... makes sense. The hyperparathyroidism can be primary (overactive gland) or secondary (such as reaction to Vitamin D deficiency and consequent calcium deficit). Good to see endocrine for this I agree, and hopefully all will be corrected by the time of the next blood draw!
P.S. I think "pseudopseudohypoparathryoidism" is one of the longest words in the medical dictionary, just in case you want to sound impressive at a dinner party.
https://rarediseases.info.nih.gov/diseases/7860/pseudopseudohypoparathyroidism
Hey Ryan,
Nice work but you need to work on your handwriting, too legible for a doctor.
If one does decide to supplement for whatever reason, they should look at this site I mentioned in a few of my posts. https://www.opss.org/
I do take multivitamins but within RDA. In my old age, I am discovering the wonderful world of senescence. Taking into account the many metabolic changes such as digestion, seems a logical approach. However, anyone looking into this should avoid the weeds (as I pointed out before - many things like to bite you). The multibillion supplement industrial complex like to paint a "anti-aging" picture.
Thanks KB, and I will try harder to write sloppily next time, thanks for the credibility reminder ;)
Great links provided, and I appreciate and agree with your approach to "senescence." It really is the word of the moment, and Eric Topol has been highlighting some of the research coming out about senescent cells causing chain reaction senescence down the line. I'm sure you've read that too!
Dr. McCormick, you are a hero for sorting through all this to make it clear! I have to say, I long ago gave up on figuring this out. For one, it seems to be a moving target. For another, it’s a bona fide drag to have to count up units on everything you eat. I do take D3 1000, as I am persuaded it’s impossible to get what you need from food alone, but for calcium I remain in “stay out of the pill box” mode, rely on food, and hope it’s enough. Re the dairy, while I try to stay low fat where I can, I appreciate the Skeptical Cardiologist’s comment that full fat dairy isn’t a concern for increased cardiovascular risk. On that note, for lunch today, I am going to indulge in melted cheese and tomatoes on Orwasher’s Cabernet Rustica bread (really delicious bread, BTW—you can buy a loaf sliced and frozen, so for small households, it doesn’t go to waste).😎
Man, if you heard a stomach growl a couple seconds ago that was me after reading the "melted cheese and tomatoes on Orwasher’s Cabernet Rustica bread." Seriously my stomach is rolling around and insisting I feed it now! I also highly appreciate when cardiologists validate what I have been reading over the past 5-10 years about dietary fat, and even saturated dairy fat, not being the smoking guns of CV disease. "Everything in moderation" keeps winning the day, and your approach to calcium/D sounds low tech and perfect.
Thanks for this! I WISH I could meet you in the dairy aisle! I’m dairy-free due to Alpha-gal, but will check my nondairy “milk” for its added benefits.
Hi Donna - Alpha-gal is such a hard one to adjust to, presumably from a Lone Star Tick Bite perhaps? No need to answer, but I have a few people in my practice with this now. Let's meet in the organic fruit and vegetable section then... Have a good weekend!
Excellent summary of an ongoing confusing topic. Thank you
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Thanks Marty! I'm going to let this subject go now and just remember the bottom line numbers and goals... now where did I put those yellow sticky notes?!
I LOVE this post and (the post-its). I eat yogurt, leafy greens and cheese every day but I still think I’m falling short. I just wish I could down a glass of milk but I find it so unpalatable, almost mucus-like. I am allergic to most nuts and find soy milk even more unpleasant. Can anyone give me suggestions of how to best disguise milk so that I can just get it down, shot glass style? Add chocolate? Blend with a banana and freeze and make a “fake” ice cream? Asking seriously! 😂
Hi Lindsey, and thanks for the humor! Our daughter has a tree nut allergy, so I understand how vigilant you must be all the time with food. I don't like soy/oat/other "milks" either, but I do like non-homogenized whole milk (they sell at whole foods), with a slick of "butter" on top that you have to stir in yourself. Makes amazing hot chocolate, but obviously too much sugar for a regular source. I like your idea of sneaking some milk into smoothies. ChatGPT came up with this pretty classic one just now:
Ingredients:
1 cup whole milk
1 ripe banana, sliced
1/2 cup frozen berries (such as strawberries, blueberries, or raspberries)
1 tablespoon honey or maple syrup (optional, for sweetness)
1/2 cup Greek yogurt (optional, for added creaminess and protein)
1 tablespoon chia seeds or flaxseeds (optional, for extra nutrients)
Handful of spinach or kale (optional, for added greens)
Thank you.
Stonyfield is a good yogurt but I would encourage you to try the non low fat versions.
And having made 81, you are definitely entitled a filet mignon!
Dr. p
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Personalization factors for Vitamin D treatment include:
Body size: less for youths, more for obese
Have genes that reduce Vitamin D blood level (which can be measured)
Have genes that restrict the amount getting to cells
Measurement of PTH may be a proxy for Vitamin D level in cells
One of the genes, that deactivates the Vitamin D Receptor, can be activated 16+ ways
Have a disease associated with Low Vitamin D
Have a disease that consumes a lot of Vitamin D
Have a disease that is associated with poor Vitamin D response (Asthma, etc.)
Have a disease that can only be fought by high levels of Vitamin D (such as MS, psoriasis)
Have a disease that deactivates the Vitamin D Receptor (COVID, Breast Cancer, etc)
Have a poor gut – which decreases bio-absorption of Vitamin D (May need a gut-friendly form)
Have had gal bladder removed – which decreases absorption of fat-soluble Vitamins
Smoking
Taking drugs that reduce Vitamin D
Having a medical procedure that decreases Vitamin D level (Dialysis, surgery, etc.)
Have a disease that is associated with low Vitamin D (Diabetes, etc.)
Have a disease that is associated with a poor Vitamin D response (Asthma, etc.)
Unable to or dislikes swallowing pills (powder, liquid, spray, and topical forms are available)
Was born preterm or mother had low vitamin D while pregnant
increases risk of many Vitamin D diseases up to 50 years later
Have diseases that run in the family that are associated with low Vitamin D
Have little ability to get Vitamin D from the noonday sun
Concealing clothes, far from the equator, dark skin, avoiding the very hot sun,
shift worker, nursing home, wheelchair
Are in a very stressful situation
Have poor liver or kidney (needed to metabolize vitamin D in the bloodstream)
Have a poor lymph system (required to get Vitamin D in the intestine into the blood)
Loading dose if signs of improvement are needed in a month instead of within a fraction of a year
The above are all documented in VitaminDWiki - Solutions include:
different dose, different form, UV lamp, cofactors, non-daily dose
Hope to have an interactive service on VitaminDWiki before the end of 2024 which will allow visitors to quickly and easily get personalized Vitamin D recommendations