My research into what is needed for healthy bones was prompted by weak and easily broken fingernails. It makes sense that fingernail and bone health would go together, and indeed they do. Part 1, here, covers vitamin K, which is essential and usually lacking. That served me well for some time, until, in spite of taking K I started having trouble again. We continue now in the quest to find out what else is needed. Do read on, because it turns out we get a big bonus in reduction of cancer risk as well. . .
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Vitamin D
The effect of Vitamin D on bone density has been studied quite a bit, and the results on that score have been mixed. It has been shown to improve bone density in young girls, but studies in post-menopausal women have come up empty handed. I reasoned that if vitamin K2 is missing, D will not make any difference. So I searched and found a study that compared placebo with K2 only, D only, and both K2+D. Vitamin D didn't make any difference in bone density there either. So is that it? No.... Strength and density are not the same thing. In 2013, Busse et al (pdf) found that vitamin D deficient bone is dense, but lacks the fracture resistance of healthy bone:
calcium weight percentages... were ... 10% higher in vitamin D–deficient bone ... this increase in the percentage of Ca is consistent with an advanced tissue age
yet,
a lower fracture resistance in vitamin D–deficient bone, with a 31% decrease in crack initiation toughness.... and a 22% decrease in crack growth toughness
So vitamin D deficient bone was actually denser than healthy bone, yet more easily fractured. This was a laboratory study. Is this result borne out in actual practice? The gold standard is the randomized controlled trial ("RCT"). Even better is a meta-analysis - a study pooling all of the RCTs to date. Let's take a look at the most recent one (pdf), from 2012:
We included 31,022 persons .... By quartiles of actual intake, reduction in the risk of fracture was shown only at the highest intake level (median, 800 IU daily; range, 792 to 2000), with a 30% reduction in the risk of hip fracture... and a 14% reduction in the risk of any nonvertebral fracture ... Benefits at the highest level of vitamin D intake were fairly consistent across subgroups defined by age group, type of dwelling, baseline ... vitamin D level, and additional calcium intake.
Lesser amounts of vitamin D daily made no difference. So 800 IU /day is the minimum. What is the optimum? The relationship between vitamin D levels and all cause mortality (pdf) was measured by Melamed in a population of 13,000 people over 20 years. He found that lowest mortality occurred over a blood concentration in the range of 30-50 ng/ml (nanograms per milliliter). At lower levels of vitamin D mortality was quite a bit higher. At higher levels of vitamin D mortality also started to rise, but not as steeply. Other studies have found this type of "bathtub" curve as well.So how does that translate into a dosage recommendation? Optimum dosage varies somewhat with the individual, depending on factors such as diet and sun. Here is one take:
So far as can be judged from numerous studies documenting the magnitude of the effect of sun exposure ... the primitive intake would have been at least 4000 IU/day and probably two to three times that level, with corresponding serum ...D levels ranging from 40 to 80 ng/mL.
Personally, after taking 5000 IU/day for some time, my blood level measured 32 ng/ml. Based on that reading, my doctor recommended raising it to 7000 IU/day. A rule of thumb is that every additional 1000 IU/day raises the blood level by 10ng/ml. How much is too much? (pdf)
The overwhelming bulk of clinical trial evidence supports the conclusion that a prolonged intake of ...10,000 IU/d of vitamin D3 likely poses no risk of adverse effects
Besides bone strength, is there anything else vitamin D does for us? Here's something: Vitamin D and calcium supplementation reduces cancer risk: results of a randomized trial (pdf)
1179 community-dwelling women ... randomly assigned to receive 1400–1500 mg supplemental calcium alone (Ca-only), supplemental calcium plus 1100 IU vitamin D...(Ca + D), or placebo.... cancer incidence was lower in the Ca+D women than in the placebo control subjects (P< 0.03). ... relative risks (RR) of incident cancer in the Ca+D and Ca-only groups were 0.402 (P<0.01) and 0.532 (P<0.06), respectively. *When analysis was confined to cancers diagnosed after the first 12 mo, RR for the Ca + D group fell to 0.232* (CI: 0.09, 0.60; P < 0.005) but did not change significantly for the Ca-only group.
Wait ... what? After one year, cancer risk in the Ca + D group was only 23% that of the untreated group. That P value - P<.005 says there is only one half percent probability this result was due to chance. This could be a big reason why vitamin D reduces all-cause mortality.
The current study is, to our knowledge, the first randomized controlled trial that involved a vitamin D intervention sufficient to raise serum ... D ... and reported a cancer outcome. Our findings of decreased all-cancer risk with improved vitamin D status are consistent with a large and still growing body of epidemiologic and observational data showing that cancer risk, cancer mortality, or both are inversely associated with solar exposure, vitamin D status, or both
To summarize what we have found — Vitamin D doesn't do anything for bone density, but it reduces fracture risk, and with calcium, dramatically reduces cancer risk. A note regarding the foregoing - to be precise, all references to the oral form of vitamin D have been to vitamin D3. There is also a D2. All references to plasma levels of vitamin D have been to 25-hydroxy vitamin D, commonly designated by "25(OH)D". During the past week, as I was researching this topic, a general news headline announced the results of a new study of vitamin D supplementation:
the effect was small and did not translate into beneficial effects ... We found no data to support experts’ recommendations to maintain serum ... D levels ... Instead, we found that low- and high-dose ... were equivalent to placebo in their effects on bone and muscle outcomes ... Outcome measures were ... bone mineral density and muscle mass
Fracture risk? cancer risk? Not measured. They. only. measured. bone. density. We already know that vitamin D does not affect bone density. A specialist in the field could hardly claim ignorance. However, doctors don't always disclose conflict of interest. Worse, journal articles are often ghost-written by big pharma marketing departments:
Estimates suggest that almost half of all articles published in journals are by ghostwriters. ...These papers endorsing certain drugs are paraded in front of GPs as independent research to persuade them to prescribe the drugs. ...In February the New England Journal of Medicine was forced to retract an article ... The deception was revealed only when German cardiologist ... called the editor of the journal to say he had never seen any version of the paper ...An article published last February... involved a medical writer working for drug giant AstraZeneca - a fact that was not revealed by the author.
Doctors collect dollars for putting their name on the article:
the pharmaceutical company would pay a communications/marketing company to write the manuscript, who would then go out and find academics who would be willing to become the “authors” of the manuscript and paid an honorarium.
A former ghostwriter has chosen to speak out:
ethical issues .. the most memorable example of this was a contraceptive product that caused severe, unpredictable vaginal bleeding in some women
More here and here. For an intimate look at how big pharma goes about skewing trial results and spreading propaganda, here's a book by an MD who has been on the front lines. But why would anyone want to plant misinformation on vitamin D? Just for fun, I took a look at bisphosphonates (Fosamax, etc.), to compare what they did for fracture risk, anticipating I would find them comparable to vitamin D. I searched like this ... and found this (pdf):
Oral bisphosphonates may not decrease hip fracture risk...The study included 2,009 incident hip fractures and 10,045 matched controls.... use of oral bisphosphonates was not associated with a decreased risk of hip fracture in women aged 65 or older... a statistically significant increased risk for hip fracture was observed in patients exposed to bisphosphonates over 3 years.
Wait.. what? ... ok lets try again:
Cumulative Alendronate Dose and the Long-Term Absolute Risk ... Patients were alendronate users ... (n = 39,567) and untreated controls, (n = 158,268) ... subtrochanteric and diaphyseal fractures occurred at a rate of 13 per 10,000 patient-years in untreated women and 31 per 10,000 patient-years in women receiving alendronate
Huh? OK, I know where to find the positive data - the manufacturer's prescribing information: (pdf)
In the Three-Year Study ...fractures of the hip occurred in 22 (2.2%) of 1005 patients on placebo and 11 (1.1%) of 1022 patients on FOSAMAX, p=0.047.
A 51% reduction in fracture risk. That is great - but look at the p value - just barely squeaking by the p < .05 limit. The reason for this is they only ended up with 33 fractures from 2000 patients. Compare that to the first bisphosphonate study above with 2,000 fractures and 12,000 patients, and the second study with 200,000 patients. To say the least, this raises questions about bisphosphonates. It would also be a motive for someone to want to confuse the public about the value of vitamin D. With billions of dollars at stake, there is a strong incentive to skew the data and the public perception, truth and patient welfare be damned.
As I mentioned, I had already been taking vitamins K2 and D since the earlier diary a couple of years ago. Nonetheless, recently, my fingernails became weak and easily broken once again. Was there anything else I was missing? Here is what I found:
Silicon
A review of the role of silicon in bone health can be found here (pdf)
Average daily dietary intake of silicon is 20–50mg for European and North American populations ....Daily intake of silicon is higher in China and India (140–200mg/day) where grains, fruits, and vegetables form a larger part of the diet ... China and India also have the lowest prevalence of hip fractures compared to all other regions of the world.
Intramuscular injections of silicon as monomethyl trisilanol at a dose of 50mg twice a week for four months were administered to postmenopausal women with osteoporosis. This treatment was compared to etidronate, fluoride, magnesium, and controls ... Patients in all groups received 1000mg of calcium and 500 IU of Vitamin D daily. A significant improvement in femoral bone density was noted in the silicon group compared to the other groups.
Here are some dietary sources of silicon:
Portion size mg/portion Beer 12 oz 8.25mg Raisins 100 gm 8.25mg Green beans 250 gm 6.10mg High-bran cereal 100 gm 10.17mg
Aha! A good reason to drink beer. Unfortunately it would take quite a bit. Silicon is also available as a supplement, in the form of silica, which is about half silicon by weight.
Boron and Other Trace Elements
Boron (pdf) is increasingly recognized as an element that has several health benefits including bone health .... The precise mechanism of action of boron for bone health is unknown, but boron stabilizes and extends the half-life of vitamin D and estrogen... Supplementation with 3 mg. of boron per day for post-menopausal women has demonstrated improved calcium and magnesium retention by the kidneys
A number of studies in the lab with human cells, and animal models, show that boron is beneficial for bone health.
Magnesium is increasingly recognized as an important contributor to bone health .... A study of women with osteoporosis in Israel reported significantly increased bone mineral density with 250 mg/day of magnesium supplement when compared to a control group who did not take magnesium supplements
Some essential nutrients for bone health are readily available in the typical American diet. These include zinc, manganese, and copper
I was already taking magnesium and zinc for other reasons. I also had plenty of calcium in my diet. I decided to add silica and boron to my K2 and D supplements. Voilà, this did the trick, and fingernails are back to health.
Update 2019: I have also found that glucosamine chondroitin is another important ingredient for fingernail, and presumably, bone health.
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