Author: David Wells, D.C., L.Ac.

Dr. David Wells has been licensed as a Chiropractor since 1979 and as an Acupuncturist since 1985. He also holds a Master's Degree in Psychology and a Master's in Clinical Nutrition. His clinical experience extends over 40 years of continuous practice. Along the way, he has been President of the California Acupuncture Association, President of the Council of Acupuncture and Oriental Medicine Associations, Bylaws Chair for the American Association of Acupuncture and Oriental Medicine, Founder of AcuNet (Acupuncture Provider Network) and Medical Director of Landmark Healthcare. In the latter capacity, he brought acupuncture as an insured benefit to 17 states. He wrote and presented for approval the CPT codes that allow acupuncturists to bill for their services and has taught numerous seminars around the country.

Double rainbow at Kodachrome State Park

Super Slow High Intensity Strength Training

The safest way to build muscle quickly is to do resistance exercise very slowly. When I say slow, I mean 2 – 3 repetitions per minute. That’s why it’s called Super Slow. This kind of exercise makes Tai Chi look fast.

Which exercises? Really any normal strength move. Let’s say you like to do bicep curls with a dumbbell. First thing to know is that any exercise you select is much harder to do when you go slow. Because of that, you will want to start with about half the weight you are used to lifting.

Why is it harder? Because the way a muscle works uses energy at three stages: First, energy is used to release the bonds between the hundreds of individual muscle fibers. Then, energy is used to shorten those muscles fibers. Next, the fibers have to bond again to one another in a shortened position. This cycle repeats until the movement is completed. When you lift at a normal speed, these energy-intensive bondings, contractions and un-bondings happen just a few times as the muscle contracts through the full range of motion. The slower you contract your muscle, the more times the muscle has to un-bond, contract and re-bond to go through the full range of motion. A single, super-slow bicep curl is much more work that several quicker ones because you get no benefit from momentum or speed. It can be the same effort as ten “normal” repetitions.

Why is this better than just lifting heavier or more repetitions? Because injuries happen when connective tissue is rapidly stretched. It’s hard to hurt yourself when you go slow. Compare a very smooth, slow lift with jerking the dumbbell up using momentum from hip movement to get started. That sudden acceleration can tear tendons and ligaments. The initial acceleration also gets the weight up into the mid range of the bicep contraction where the muscle is strongest. Lifting slowly from a dead hang forces the muscle to work in a disadvantageous position.

Another benefit of slow is that it gives you time to focus on your form. As noted above, going slow encourages you to go through the full range of motion, working on the more difficult parts of your exercise. Another element I try to create in strength training is to add some kind of instability. This trains balance, coordination and almost always recruits the abdominal muscles. In the case of a bicep curl while standing and holding the dumbbell in your right hand, bend and lift your left leg so that your foot is resting on a stability ball. The resulting instability will require you to recruit a lot of other postural muscles.

You can understand now why it’s important to start out with a lighter weight that you usually lift. So what if your preferred exercise is pushups? How do you lift less weight? You can start by doing your pushups against a counter. As you get better, try lifting one foot off the ground to create instability. As your strength improves, you may end up doing pushups in a standard plank position on the floor, but with one foot resting on a soccer ball to create instability. Try doing two of those per minute. Trust me, it’s a challenge.

That brings me to the high intensity part of this type of training. When you are comfortable with the form of your exercise, you want to make it increasingly more difficult until you reach your desired level of fitness. My strategy is to only do any one exercise for a minute. That’s all, one minute. I don’t have a lot of time to devote to exercise, so I want to make the most of the time I have. To get the most out of exercise, I do what’s called “one minute to failure”, meaning that I am giving my maximum effort to the point that I can just barely finish the minute without collapsing.

So there you have it. Super slow, high-intensity strength training. Safe, quick and effective.

Cardiovascular and Metabolic Disease

What You Need to Know to Prevent Cardiovascular and Metabolic Disease
by David Wells, D.C., L.Ac., M.S. (Nutrition)

Four centuries ago the English physician, Thomas Sydenham MD (1624 to1689) said, “A man is as old as his arteries.” That statement is as true today as it was then. Our lives are utterly dependent on the 1,800 gallons of blood pumped through our arteries each day. This miracle of oxygen delivery is so critical that we can only survive minutes without it, yet the gradual decline in our circulatory system is barely noticed. To understand how our circulatory system ages and what we can do to slow that aging process, we must first understand how it works.

The heart and blood vessels are not two separate systems like a pump and a hose. It is better to think of the blood vessels as a continuation of the heart. That is, the heart contracts, pumping the blood out into the aorta (the first artery). The aorta swells like a balloon to accommodate all that blood and then it contracts back to it’s original shape, squeezing the blood forward. This process continues as the blood divides into progressively smaller arteries until the blood vessels (by this point called capillaries) are so small that individual blood cells can only fit into these tiny passageways in single file. At this micro level, the oxygen is released from the red blood cells into the tissue cells that line the capillaries. Every single cell in your body whether it is in your muscles or your brain, is adjacent to a capillary. The oxygen given up by the blood cells is replaced with carbon dioxide released by the tissue cells and carried back to the lungs to be exchanged for more oxygen. That way, every cell is provided with fresh oxygen and other nutrients while the carbon dioxide and other wastes are carried away. Pretty amazing. It’s like 24-hour room service to trillions of cells.

On the return trip from the capillaries, the returning blood collects in progressively larger vessels called veins. The pulse pressure from the heart is no longer sufficient to propel the blood back to the heart, but each vein has one-way valves pointing towards the heart. As our skeletal muscles contract, pressure from those contractions pushes the blood back first to the lungs and then on to the heart. The whole system of heart, blood vessels, muscles, etc works together in a coordinated way to circulate the blood. The arteries must be elastic and strong to propel the blood on it’s way from the heart to the tissues. Skeletal muscle contraction is needed to the return the blood to the heart. This last point explains why the muscles of the lower leg are sometimes referred to as “the second heart.” Calf contraction (such as in walking) takes a load off the heart by propelling the venous return of blood to the heart. That’s one reason why walking is so good for your heart.

Tip number 1 walk 30 minutes or more per day.

So what happens in aging? To understand that, it helps to know a little about the structure of the arteries. The arteries are made of three layers. The innermost layer is called the “intima”. To help remember the name, think of this inner lining as being “intimate” with the blood itself. The endothelial cells that line the intima sense changes in the blood and send signals to the middle layer to help the artery adapt to those changes. The middle layer is called the “media” and is made up of concentric rings of smooth muscle cells that contract to propel the blood forward. The outer layer is composed mainly of connective tissue and is called the “adventitia”.

In aging, the intima thickens, stiffens and accumulates plaque. The plaque is made primarily of scar tissue and cholesterol. We’ll get back to how that happens in a moment. Stiffening of the artery wall puts more load on the heart and may eventually cause it to fail. Stiffening also creates more resistance to the flow of blood and raises blood pressure. The plaque can thicken to the point of blocking an artery or a chunk of plaque may break off and cause a stroke or pulmonary embolism. An embolism is a clot that can block a blood vessel causing death to the tissues deprived of oxygen by the blockage. How this happens and what you can do to prevent it is the subject of the article (Hint, the answer is not cholesterol).

What causes thickening of the intima and plaque formation?
In a word, the answer is inflammation. What then causes inflammation? Exposure to oxidants like smoke (everything from cigarettes to pollution), rancid polyunsaturated fats and fried foods, numerous chemicals (everything from solvents, paints, plastics, gasoline, cleaning products, etc), obesity, diabetes and oddly enough, even the iron in your blood that carries oxygen to your tissues.

The way all these diverse substances provoke inflammation is a chemical reaction called oxidation. To illustrate what oxidation looks like, pour some hydrogen peroxide on your toothbrush. You will see a fizzing cluster of bubbles form on your toothbrush. What’s happening? Peroxide is an unstable combination of hydrogen and oxygen (H2O2). Peroxide tries to become stable (H2O and O2) by ripping apart bacterial cells on your toothbrush to grab an extra molecule of oxygen. That’s what creates the fizzing bubbles of water and oxygen. It also creates dead bacteria because the peroxide rips oxygen molecules away from their cell membranes.

A similar process happens in our arteries. Exposure of the intima to any oxidative chemicals (also known as free-radicals) causes cells lining the intima to be ripped apart. To repair that damage, the immune system uses specialized cells called fibroblasts that make fibers of scar tissue to bind the damaged area back together. Picture stitching a wound together. That repair process is provoked by the chemistry of inflammation. After stitching the damaged area back together, the fibroblasts grab cholesterol from the bloodstream to pack it into the spaces between the fibers of scar tissue. Why do the fibroblasts pack cholesterol into the spaces between fibers of the scar? The cholesterol forms a smoother surface on the scar, reducing turbulence in the blood. Since turbulence can form clots in the blood, this is a good thing. That is why plaque is made of scar tissue and cholesterol. Over time, the scar tissue calcifies and hardens like bone (see my article on osteoporosis for more on that).

So cholesterol is just a building material? Yes, in fact it is one of the most common building materials in the body. Every cell membrane is made of cholesterol (plus omega-3 fats and a few other things). It is a building material like a brick (solid, water-proof and stable). It is also the base molecule of all steroid hormones like estrogen, testosterone, prednisone, cortisol, etc. Even vitamin D is made from it. The myelin sheaths that insulate all our nerves are made from it. The brain is almost 50 percent cholesterol. Cholesterol is not some evil foreign substance. We make cholesterol in our liver because we need it. That’s right, ninety percent of the cholesterol in our bodies is made in our livers. Only ten percent comes from our food.

So why are doctors always trying to get us to reduce our cholesterol levels? The reason is that elevated serum cholesterol is associated with increased risk of death due to cardiovascular disease. However, association is not the same as cause. To illustrate this idea, imagine you find a dead bird on the sidewalk. On closer examination, you see that there are ants eating the bird. Do you assume that the ants killed the bird? No, you don’t. Even if every time you see a dead bird on the sidewalk and there are ants eating it, you don’t assume that the ants killed the bird. Why? Because ants don’t fly and aren’t able to kill a bird. The same is true of cholesterol. Just as the presence of ants confirms that the bird is dead, elevated cholesterol confirms that the body is out of balance.

Elevated cholesterol is one of the markers of what has been referred to as “metabolic syndrome”. Other markers include elevated triglycerides (another kind of fat) and blood sugar, high blood pressure and increased waistline. In other words, the most common reason for elevated cholesterol is eating more calories than you are burning. There can be a number of reasons for this imbalance. One of those reasons is low thyroid (not enough calories burned). Lack of exercise is another (again, not enough calories burned). Too many sweet tasting foods, particularly those made with high fructose corn syrup is another (too many calories consumed). High stress plays a role (greater demand for cortisol, requiring greater production of cholesterol). Not enough fiber in the diet (fiber carries cholesterol out in the stool). The answer is less likely to be that you ate too much cholesterol. It is certainly not because you have a deficiency of statin drugs (more on that later).

Tip number 2 check your thyroid health and metabolic rate by checking your basal temperature.
Tip number 3 increase exercise.
Tip number 4 avoid sweets, especially those made from high fructose corn syrup such as in soft drinks.
Tip number 5 manage your stress through exercise, life changes, Tai Chi or Yoga, vacations, rest and adding more pleasure to your life.
Tip number 6 eat large salads and flax meal to increase your fiber intake.

Metabolic Syndrome
While you don’t hear much about this by name, this is what’s killing the majority of people in the industrialized world. The names we know metabolic syndrome by are heart disease, stroke, diabetes, cancer and obesity. Together these diseases kill over half (around fifty-five percent) of people in the United States.i Metabolic syndrome is a disease of affluence. It is only possible in a society that can afford to eat more and move less. Most of human history was spent working very hard to get enough to eat, so we are strongly programmed to like the taste of high calorie foods. If you had to run down an antelope for dinner, you would also appreciate rest and relaxation. To this day, people in the Third World burn a lot more calories than we do just trying to stay alive and they don’t get nearly as much to eat as we do. Also, the foods they do eat are high in fiber, vitamins, minerals and other nutrients – not high in sugar and fat. We have solved the problem of getting enough to eat and enough rest. Now we have the problem of getting too much to eat and too little physical activity.

The simplest measure of metabolic syndrome is your waistline. If you do nothing else with this article, get out a tape and measure yourself at the waist and the hips. Your waist should be ten percent smaller than your hips if you are a man and twenty percent smaller if you are a woman. When your waist gets bigger than this ratio, you have a significantly increased risk of getting diabetes, cancer, stroke or heart disease. In the Nurses Health Study, women who had the highest waist sizes – 35 inches or more – had nearly double the risk of dying from heart disease compared to women who had waist sizes less than 28 inches.i How long has it been since your waist was that much smaller than your hips? Think about it. The visceral fat packed around the waist is like dynamite. I see a lot of suicide bombers walking around every day. In fact, according to the CDC nearly three-quarters of men and more than 60% of woman are obese or overweight.ii

Tip number seven Measure your waistline.

So how do you measure yourself? Slide your hands down your sides until you come to the bottom rib. This is your waist. It is above, not below your navel. Wrap a cloth tape measure around yourself at this level and write down the measurement. Then, slide your hands down farther to find the widest point of your hips. Your hips should feel firm because the widest point are comprised of the bones of your hips. Wrap the tape around that area and write down that measurement. Now divide the waist measurement by the hip measurement and subtract the total from 100 to get the percent difference. So for example, if a woman measures her waist at 32 inches and hips at 40 inches, here’s how the formula looks: 32/40 = 80. 100 – 80 = 20. So the answer is twenty percent.

Another way to look at it is if your hips are forty inches, your waist should be thirty-two inches or less. So if you are up to thirty-four inches, you have two inches to lose. How many pounds is that? It’s around four pounds per inch but pounds aren’t the goal, inches are. If you were lose two inches off your waist but not lose any weight, then it is likely that you lost eight pounds of fat and gained eight pounds of muscle. That would be fabulous. So focus more on losing inches from your waist and less on losing pounds. If you lost eight pounds but your waist remained the same, that would be a disaster as it would mean you lost eight pounds of muscle. Since muscle is what burns fat, people who lose muscle in a weight loss program will gain back more weight as soon as they begin to eat anywhere near enough to satisfy their hunger. That is how extreme dieting causes extreme weight gain.

Besides the waist to hip ratio, there is an absolute upper limit to waist size to prevent all these deadly diseases. For men, that upper limit is 40 inches. For women, it is 35 inches.

“Losing inches is hard,” people say. Yes it is, but there is no better way to prevent the major killer diseases. I frequently hear, “Can’t I just take a pill to lower my cholesterol?” The answer is “Taking a pill will not help you to avoid heart disease, stroke, diabetes and cancer.”

Cholesterol lowering drugs.
Before going on, I want to repeat that cholesterol is not the problem, inflammation is the problem. Despite that, researchers have developed drugs to lower serum (blood) cholesterol in the assumption that this will lower the risk of death from heart disease (Kill the ants to save the birds?). What these drugs actually do is lower a number on a lab test without providing significant protection. They also cause serious harm.

To hear all the breathless reports on the miracles of statin drugs, you would think everyone needs to take them. You would think they will save your life or at least substantially lower your risk of death. They do not. At best, they provide a mild benefit for a subset of middle-aged men who are at high risk of heart attack. To listen to the hype, you would assume that they cut your risk of death by 80% or 50% or at least the 20% commonly attributed to placebo effect. This is not the case. One of the strongest studies in support of statins was the WOSCOPS study. This study of middle aged men treated with Pravastatin showed a 0.6% reduction in death rate. Given the price of the drug and the number of men who would have to take it to get a benefit, that would amount to 1.2 million dollars to extend one man’s life by five years.

Zero point six percent! This is the life saving, miracle drug that everyone needs to take? In my opinion, it is only a life-saving miracle for the pharmaceutical industry. Statin drugs generate 29 billion dollars a year for the drug companies. We hear a lot of press about statins. We don’t hear much about cheap, natural alternatives. How much do you think the lettuce lobby spends on advertising? Or, the flax meal consortium? Not much, I’d guess.

Combining the results of many studies gives a more accurate picture by creating a greater sample size. This is called a meta-analysis. The largest such study, a 2010 meta analysis of 65,229 participants, did not find a reduced death rate in those at high risk but without prior cardiovascular disease, for those who took statin drugs.ii

Having failed to prove that statins lower the risk of death due to heart attack, drug company researchers looked for another justification for the use of statins. Normally, researchers investigate a question without prior bias. Research may be called, “Study to determine if statins lower the risk of death” for example. That was not the case in this study. The name “Jupiter” study stands for Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin. In other words, the title of the study reveals that the researchers were biased in their intention to find a justification for the use of statins.

Despite the glowing press reports, the Jupiter Study, found that statins did not significantly lower the overall death rate in the men (that’s right, it too wasn’t tested on women) who participated in the study. There was a reduction in non-fatal cardiac events in the statin versus placebo group and the overall rate of cardiovascular deaths were lower, 0.45% for the statin group versus 0.85% for the placebo group. This was reported as “cutting the death rate in half” by the press but what was not reported is that the death rate from all causes was 27% higher in the statin group.iii In fact, there were more fatal heart attacks in the Crestor group (9 versus 6) than in the placebo group.

Something else buried in the fine print of the study is that the placebo and statin groups were not equal. The placebo group had 51 more subjects with a family history of premature coronary heart disease than the statin group. Also, there were 71 more patients in the placebo group than the statin group that had Metabolic Syndrome. These are the two greatest risk factors for dying of a heart attack. One last note on the study relates to cost. If you have to treat 180 people to prevent one death from a heart attack, factoring in the price of the product means that it would cost about $500,000 to prevent one death. If that half million were used to combat smoking or obesity, far more lives could be saved.

How did we get to this point of thinking that reducing cholesterol was going to reduce heart attack risk? Back in the 1950’s, Broda Barnes, MD wrote a book called The Riddle of Heart Attacks Solved. In it, he pointed to research showing that rabbits fed a high cholesterol diet showed no change in their health despite the fact that cholesterol is not a normal part of their diet (How’s that square with all the advice to lower your dietary cholesterol?). The research did show that when the thyroid glands of the rabbits were removed, they became obese, developed fatty deposits in their arteries and died of cardiovascular disease. When thyroid hormone was given to the surviving rabbits, the arteries cleared and their health returned to normal. In his practice, Dr. Barnes found that normalizing metabolism prevented heart disease. He primarily treated his patients using Armour Thyroid (porcine thyroid tissue). He diagnosed by asking his patients to take their temperature every morning. He adjusted the dose of the thyroid medicine to normalize their temperature at 98.6 degrees. His work was generally ignored by the medical profession and the public.

The person who really brought cholesterol to the public’s attention was Nathan Pritikin. Beginning in the early 1980’s, the Pritikin Center helped many people restore their health by teaching that a low fat, low calorie diet combined with a lot of mild aerobic exercise could dramatically reduce the risk of death from heart attack, stroke, diabetes and cancer. Pritikin’s program made the news and put the word “cholesterol” on everyone’s lips. But who wants to exercise and eat salad? The drug companies saw an opportunity.

A few years prior, in 1976, a Japanese researcher named Akira Endo found a compound in red rice yeast that interfered with the liver enzyme that produces both cholesterol and coenzyme Q10. This inhibitor is called mevastatin. In 1979, researchers at Merck isolated lovastatin from another fungus. By 1987, Merck used that research to develop the first statin drug, Lipitor. Merck patented the right to co-market their drug with CoQ10 but never did, effectively preventing any other drug manufacturer from doing so as it would be a patent infringement. In my opinion that was a crime against humanity.

What is CoQ10? It is an enzyme that is needed by the body to burn fat and oxygen to make energy. Without CoQ10, all cells would die. This was proved by the statin drug, BayCol (made by the Bayer company). BayCol was so effective at blocking the liver enzyme making both cholesterol and CoQ10 that the muscle cells in the people who took the drug died in massive numbers. So quickly did the cells die, that the waste products of these dead cells clogged up the kidneys of these patients and they died of kidney failure. After 52 confirmed deaths, BayCol was removed from the market.iv The next strongest statin drug is Crestor, the one used in the Jupiter Study.

One of the best known side effects of statin drugs is pain, weakness and muscle wasting, particularly in the legs. This is undoubtably due to the lack of CoQ10. It’s worth noting that CoQ10 is used to treat weakness of the heart muscle. It stands to reason that if the muscles of the leg are getting smaller and weaker from being deprived of CoQ10, so is the heart. The heart is after all, a big muscle. How’s that for a drug that’s supposed to save us from dying of a heart attack?

The risk of weakening the heart muscle is not just theoretical. Statins were first approved in 1987. From 1989 to 1997 the rate of heart failure in this country Statins may have slightly reduced the rate of non-fatal heart attacks but increased rates of death from heart failure. Heart failure doesn’t kill you all at once either. Have you ever heard the term “cardiac cripple?” That term describes a person with heart failure who is unable to walk or do many activities of daily living because their heart is so weak.

How common is the risk of muscle deterioration? The risk of catastrophic destruction of muscle tissue (rhabdomyolysis), which can lead to kidney failure and death is 61 out of every 1,000 patients who take doses of 80 mg of Lipitor. Simvistatin in doses as low as 20 mg can cause muscle destruction if taken with a common blood pressure medication, amiodirone or if it is taken within days after consuming grapefruit or grapefruit juice. The drug companies would have us believe that the side effect of muscle pain and weakness occur in around two to three percent of patients. Dr Beatrice Golomb MD, PhD is currently conducting a study. She has found that 98% of patients taking Lipitor and about a third of patients taking Mevachor (a lower dose statin) suffered from muscle problems.vii

What other side effects do statins have? How about decreased cognitive ability? “There are reports about memory loss, forgetfulness and confusion in all users of all statin products and in all age groups.”viii Studies have shown 100% of people on statin drugs show cognitive decline. Many have also suffered total or partial amnesia and other memory problems. Early tests on non-statin, cholesterol-lowering drugs found a doubling of the risk for violent death or suicide.ix This is likely because the brain is dependent on cholesterol for healthy functioning. Low cholesterol is associated with depression and rage.

Perhaps the most frightening degenerative disease of the nervous system is Lou Gherig’s Disease or Amyotrophic Lateral Sclerosis. There is now evidence showing an increased incidence of that devastating illness linked to the use of statin drugs.x The number of cases is small, but it reinforces the idea that statins are not good for the nervous system.

Why is this? As it turns out, one of the functions of cholesterol is to cement together the synapses in the brain as they form memory. Too little cholesterol in the brain is a problem.

What else? It turns out that statins also increase the risk for cataracts. This is important because cataracts are one of the leading causes of blindness. Statin users have “a 27% higher chance of cataracts than non-users.”xi

How about diabetes? According to the British Medical Journal, statins increase the risk of diabetes by up to 22%xii In the Jupiter Study, the increased risk was 27%., more than wiping out any gains in heart attack risk.

What about statins for women? For the most part, statins have not been tested in women. However, one study to specifically test statins in post menopausal women was the ASCOT study. The results of that study were that women who took statins had a 10% increase in heart attacks compared to those who took the placebo.xiii The MEGA study, a prevastatin trial, found substantially increased risk of heart disease and stroke in women under the age of 60.xiv

Speaking of women, what about risk of fetal abnormalities? Statin drugs are classified as a “pregnancy CategoryX” medication because they are known to cause serious birth defects. No woman of childbearing age should ever take statin drugs.xv Very few doctors seem to be aware of that. The drug companies are pushing for younger and younger people to take statins as a “preventative medicine”. Pfizer has even introduced a kid-friendly, chewable form of Lipitor! No kidding. Considering that children’s brains are still developing and that many of them will someday become pregnant, this is akin to genocide.

Some of the lesser side effects noted in the Physicians Desk Reference include sleep problems, sexual function problems, fatigue, dizziness and a sense of detachment, swelling, shortness of breath, vision changes, changes in temperature regulation, weight change, hunger, breast enlargement, blood sugar changes, dry skin, rashes, blood pressure changes, nausea, upset stomach, bleeding, and ringing in ears or other noises.

Still not convinced? It gets worse. The strongest predictor of death due to heart attack is the degree to which the coronary arteries are calcified.xvi A 2012 study published in the journal Diabetes Care found that those who used the most statin drugs showed the greatest increase in calcification of the coronary arteries!xvii Wow. More statins equals more plaque equals more heart attacks. That is exactly the opposite of what we are led to believe. Conversely, Vitamin K2 actually removes calcium from arterial plaque and reduces death rate from heart disease by 50%. For more on that, see my article on osteoporosis.

To sum up, statins don’t reduce your risk of death but they guarantee that you will be weaker, fatter and dumber. That’s what every aging person wants, right? Despite that, statins are the number one class of drugs prescribed in America. What can you do about it?

Tip number 8 If you are on statins, ask your doctor if you can get off. In the meantime, take CoQ10.

The irony of all of this is that there is no evidence that cholesterol causes heart disease. Elevated cholesterol is merely the evidence of metabolic syndrome. Pritikin used cholesterol levels to track progress in his program because it is more convenient and less expensive than angiography or ultrasound to track the actual amount of plaque in the arteries. Remember, the ants didn’t kill the bird. A more reliable and readily available predictor of cardiovascular risk is your waistline. Of course, there is no money to be made in empowering people to measure their waist and improving their own health through diet, exercise and lifestyle. Taking a drug to make your lab test look better is far more profitable but simply lulls everyone into complacency. “Pass me another slice of cake. My cholesterol numbers are good!”

So if statins aren’t the answer, what is? To answer that question, it’s best to go back to our discussion on how plaque forms in response to oxidation.

Oxidative Damage to the Arteries
So to review, oxidation damages the inner lining of arteries. Immune cells called fibroblasts repair that damage using scar tissue and cholesterol. The scar tissue eventually calcifies. The blood vessels no longer expand and contract to push the blood forward and instead are stiff and resistant to the flow of blood, putting stress on the heart and raising blood pressure. The blood vessels continue to narrow, reducing the supply of oxygen. If that lack of oxygen is to the muscle of the heart, the heart can be damaged or fail completely. If a chunk of plaque breaks off and blocks the blood supply to the brain, we call that loss of function a stroke or cerebral vascular accident (CVA). If the clot lodges in the lung, it is called pulmonary embolism. Anywhere a clot blocks blood delivery, tissue dies. If enough critical tissue dies, you die. I assume that you, like me don’t want that to happen anytime soon if at all.

So what can we do? First of all, stop ingesting chemicals that cause inflammation. Second, take nutrients that reduce inflammation. If you had a headache from hitting yourself in the head with a brick, the first thing to do would be to put down the brick. Next, you would apply an ice pack to your head. Sounds obvious right?

What are the causes of inflammation? If you smoke, the single biggest change you can make is to stop hitting yourself in the head….. oh, I mean stop smoking. If you work around toxic chemicals like a nail salon or welding shop, be sure you have good ventilation. To a lesser degree of importance, if you are putting artificial anything in or on your body – yes that includes most perfumes, hair products and other fragrances – stop it. If your food has a list of ingredients that require a degree in chemistry to understand, stop eating it. An apple does not have a list of ingredients. It is an apple. Same with any other real food. As the author Michael Pollan said, “If your grandmother wouldn’t recognize it, it isn’t food.”

Tip number 9
Reduce your exposure to toxic chemicals.

Reduce sugar in the diet
Driven largely by the abundance of cheap, government-subsidized corn sugar, Americans now consume more refined sugar than anyone ever has before. How much? Between 150 and 170 pounds of sugar per person, per year according to the US Department of Agriculture. To make this easier to visualize, picture 6 cups of sugar per week. I know I am not eating that much sugar, so someone is eating my share, probably in the form soft drinks loaded with high-fructose corn syrup. Soft drinks are the largest source of hidden sugars in the American diet. A 20 oz soft drink contains between 15 and 18 teaspoons of sugar. My beverage of choice is water.

Most prepared foods are also loaded with sugar. For instance, there is 1 teaspoon of sugar in every tablespoon of ketchup. Six ounces of fruit flavored yogurt can have 7 teaspoons of sugar. Before it was sweetened, yogurt was known as a “health food”. Other former health foods such as granola are often now heavily sugared. Products marketed as “Low Fat” or “Diet” have often replaced fat with sugar. Why? Because sugar tastes good. We are genetically programmed to like a sweet taste because it was once rare. It isn’t rare any longer. Too much sugar is killing us. Perhaps that’s why the Jack La Lanne (the man who made exercise a household word) once said, “If it tastes good – spit it out.”

Of the different forms of sugar, fructose is the most damaging. I’m not talking about the fructose that you might get by eating an apple. I’m talking about fructose that is added to sodas and other prepared foods. Fructose causes you liver to make fat, raise your triglycerides, cause insulin resistance and obesity.iii A high fructose diet causes fat to deposit around the heart and internal organs.iv Daily consumption of the amount of fructose in 2 and a half cans of soda causes a 28 to 87% increase in the risk of high blood pressure.

Tip number 10 Avoid sodas and other foods with high-fructose corn syrup.

Are you getting to much sugar?
If you are eating like most people, i.e. refined grains and sugars, then the answer is yes. But what if you are being more careful with your diet? How can you be sure you are careful enough? One way is to test your blood. The common tests are fasting glucose and hemoglobin A1c. It may also be necessary to test your blood sugar with a finger prick 30 minutes and 2 hours after eating to see how your body responds to sugar in your foods.

Let’s look at these tests one at a time. Hemoglobin A1c is a good measure of your average blood sugar over time. The test is based on the fact that sugar damages proteins through a process called cross-linking or glycation. You can think of glycation as being similar to cooking. Proteins harden and become dysfunctional. These dysfunctional proteins are called Advanced Glycation End-products – AGE for short because they are a hallmark of aging tissue. In fact, advanced glycation end products are associated with atherosclerosis, kidney disease, dementia, neuropathy, cataracts and elevated blood pressure.

So what does this have to do with A1c? Elevated blood sugar damages the hemoglobin in your red blood cells. Since each blood cell lasts about 90 days, the damage to a random sample of blood cells is a pretty good, three month moving average of your blood sugar levels. The higher your average blood sugars, the more damage to your hemoglobin. The American Diabetic Association says that a hemoglobin A1c level below 6 is normal, between 6 and 6.4 is pre-diabetes and anything higher than 6.4 is full blown diabetes. As with many blood tests however, there is a difference between “normal” and ideal.

An ideal hemoglobin A1c is between 4.6 and 5.3. This equals an estimated average blood glucose of 86 to 105mg/dl. As blood glucose rises from 4.6 to 5.6 you double your the risk of cardiovascular disease.v Furthermore, an article in the New England Journal of Medicine reported that compared with people who had an average blood glucose of 100, those with an average blood glucose of 115 had an 18% increase in the risk of Brain cells, like blood cells are also damaged by glycation.

While the A1c test is a really good measure of average blood glucose, it is not infallible and should not be used alone. For one thing, the number will appear low (false good news) if you are anemic. This means that many menstruating women will get an erroneous (falsely comforting) reading.

Perhaps the most common lab test is the fasting blood sugar. The ADA (American Diabetic Association) normal for this test is anything under 100mg/dl but ideally, it should be under 86mg/dl. Why? Because people with fasting blood glucose levels above 85mg/dl have increased risk of cardiovascular disease and diabetes. A 22 year study of nearly 2,000 men found that those with fasting glucose greater than 85m/dl have a 40% increased risk of death from cardiovascular disease.vii Another study showed those with a fasting level of 95mg/dl have three times the risk of developing diabetes as those whose level is below 90.viii Remember, these people have “normal’ levels according to your lab and the ADA.

The last test is harder but may be the most important if you have concerns about developing diabetes, heart disease or dementia. I’m speaking of testing your blood glucose 30 minutes and 2 hours after a meal. This is what diabetics do, using a finger prick and test strip to monitor glucose in response to food and exercise. When I say it is harder, that is because the test has to be performed more often and of course, it involves pricking yourself.

Why do this? Your blood sugar levels normally rise after a meal. Ideally, they rise to about 125mg/dl at peak, then drop under 100mg/dl by two hours after a meal. If it rises above 140 and stays there, glycation damage is occurring in the nerves, blood vessels, eyes, brain and kidneys. Remember, glycation = aging. If you wish to be healthy in your later years, making sure you have normal blood sugar is worth doing.

So what can be done if your blood sugar is too high? Obviously, limiting quick carbohydrates is a good start. Combining what carbohydrates you do eat with fat, protein and fiber to slow absorption can also help. Some people find they need to fast or go on a ketogenic (extreme low carb diet) for a short period of time. Another strategy is to use exercise to build muscle and to deplete muscle stores of glycogen (stored sugar). When you have depleted your muscles of glycogen, you can absorb glucose into the cells without needing insulin. I have had two Type 1 diabetic patients who have controlled their diabetes without using insulin. One was a dancer and the other walked several hours a day.

Tip number 11 Know your blood sugar levels and bring them into the ideal range.

Limit Omega-6 fats fats
Another big source of inflammation is fried or rancid oils, particularly seed oils like Canola, safflower, sunflower or corn oil. You can assume that any seed oil is rancid just from the manufacturing process. Most processed foods are made from Canola or corn oil. That’s another reason not to eat them. The first reason is that they are “processed”, meaning that all the good nutrients have been removed to make them shelf stable. Generally they are high in sugar, salt and all those unpronounceable chemical additives and preservatives. If it comes in a package or a can, you probably don’t want it.

What’s the matter with these supposedly healthy seed oils like Canola or corn oil? Manufacturers and advertisers have long promoted the health benefits of these oils because they contain polyunsaturated omega-6 fatty acids.” While it is true that omega-6 fatty acids are essential, they cause inflammation and we are already getting way too much of them. It’s almost impossible to not eat too much omega-6 fats. They are in every food that comes from a seed (like bread and other flour products) and all animals that eat seeds like corn. That would be all of them, except the few animals that freely roam a pasture, eating bugs and grass and weeds. All the beef, chicken, dairy products, pork, eggs, etc. we eat are from animals that were fed corn. These animals and animal products are loaded with omega-6 fats. Even salmon is now “farm raised” meaning the fish are fed corn! Since the majority of the food we eat is grains or animals fed grains, particularly corn, we are getting way too much omega-6 fats. We don’t need more in the form of seed oils.

I mentioned that omega-6 fats cause inflammation. That means that every disease that ends with “itis” is made worse with omega-6 fats. Inflammation is also the source of pain. More omega-6 fats equals more pain. Yum, pass the French fries!

Besides making us feel miserable, why are these oils bad for our arteries? Polyunsaturated fats have lots (“poly”means many) of open, or “unsaturated” bonds. These open bonds are looking for a hydrogen to grab and bind to themselves. Kind of like magnets picking up iron filings. They can suck hydrogen ions out of your artery walls, creating little rips in the fabric of your blood vessels.

Tip number 12 Avoid polyunsaturated oils and the products made from them. That’s just about all processed foods because these oils are cheap.

Oddly enough, the “bad” saturated fats that these polyunsaturated fats have replaced are not reactive. They don’t rip up your cells. People in this country have been told to avoid animal fat like lard or butter and instead eat fats made from seed oils. Take a look at how heart disease and cancer (that’s another story) have gone up in this country since we have shifted to eating more polyunsaturated seed oils. This shift is particularly bad for any oil that is heated. The more you heat a polyunsaturated fat, the more oxygen it picks up. This makes it even more reactive. If you heat up a saturated fat, nothing happens. It has no open bonds to react to anything.

My grandmother (like everyone else in her generation and for generations before her) kept a can of animal fat (usually captured when cooking meat) on the stove. That lard was used to grease the pan when cooking anything. It was never refrigerated. It couldn’t spoil. In moderation, it wasn’t harmful.

The best saturated fats to eat are coconut oil and butter. This is because they are short-chain saturated fats. Short chain means that they are 12 carbons long instead of 18 carbons long. Our bodies and every other animal we eat makes 18 carbon chain fats. This is what we use to make cell membranes and everything else in our bodies. 12 carbon chain fats are useless building materials – like a 6 foot long sheet of plywood in a house that has standard 8 foot tall walls. They are like scraps. Our bodies burn them up to keep us warm. We don’t store them to any degree. Eating them is very unlikely to make us fat and they don’t go rancid or cause inflammation in our bodies.

Tip number 13 It’s okay to eat saturated fats, particularly butter and coconut oil.

What other fats are good?
In addition to the short chain saturated fats listed above, fats with fewer open bonds are also good. These include olive oil, avocado and nuts. Most of these contain monounsaturated fatty acids, meaning that they have only one (“mono” means single) open bond. This means that there are fewer potential sites of oxidative damage and free radical production. While these monounsaturated fats are usually non-essential omega-9 fats, they are still an important source of calories and micronutrients.

Consider how olive oil is green in color and has a distinct smell and flavor. The color, smell and flavor is provided by minerals, vitamins and flavenoids that are important for good health. They also protect the oil from oxidation. Now compare that with the lack of color, flavor and smell in commercially prepared seed oils such as Canola, safflower or corn oil. All of the healthful nutrients have been stripped out of those oils leaving only the calories. This is comparable to how all the nutritional value of whole grains and molasses have been stripped out to make white flour and white sugar.

Like olive oil, nuts have their own distinct flavor, smell and color. It’s easy to tell the difference between an almond and a pecan. Nuts also have a lot of fiber. Avocados contain a lot of Vitamins A and E. Real food has flavor – not a list of ingredients.

Interestingly, macadamia nuts contain large amounts of omega-7 fatty acids. These fatty acids have been shown to reduce C-reactive protein (a measure of inflammation) triglycerides and LDL (“bad”) cholesterol. Omega 7’s also improve insulin sensitivity and cause an increase in fat metabolism by increasing the enzymes that help to burn fat.ix

Tip number 14 Eat nuts, avocados and olive oil instead of refined seed oils.

Essential fats
Our bodies cannot make omega-6 and omega-3 fatty acids. We must eat them. As I discussed above, we already get too much omega-6 fatty acids. They are pro-inflammatory and are found in abundance in all foods made from grains or from the animals that eat grains. What about omega-3 fatty acids?

These are also essential and are harder to come by. The highest food source is cold water fish like salmon (wild caught – not farmed), sardines, cod and halibut. The highest non-animal source is flax and chia seeds. Animals that wander around the pasture and eat grasses and bugs also have high amounts of omega-3 fats. The cattle eaten by cowboys in the 1800’s had omega-3 fatty acid levels comparable to salmon. This of course was ruined by feeding corn to cattle, which in addition to making their milk and meat full of inflammatory omega-6 fats, also makes the cattle sick so they have to take antibiotics. This practice is breeding “super bugs” that threaten to make all our antibiotics ineffective. While “pastured” meats are still expensive and harder to find, more stores are offering high omega-3 eggs from pastured chickens. You’ll notice that the color of the yolks are much richer as well due to the increased amounts of vitamin A.

So why do we need omega-3 fats? Omega-3 fats are flexible and impart that flexibility to our arteries. In fact, they add flexibility and porosity to every cell in your body. Each cell is enclosed in a cell membrane. These membranes selectively allow nutrients and wastes to move in and out of the cells. These membranes are made from cholesterol and omega-3 fats.

Like I mentioned earlier, cholesterol is used as a building block. Cholesterol is impermeable to water. If the entire cell membrane were made of cholesterol, nothing water soluble would get in or out of the cell. Nutrients couldn’t get in and waste products couldn’t get out. Cholesterol is very stable. It melts at 298 degrees F. which never happens in a living body. So in addition to the solid wall provided by cholesterol, cell membranes need to have passageways to get nutrients in and waste products out of the cell. That’s where omega-3 fats are particularly useful. Their very shape is twisted and angled like kinky hair. They can’t line up next to each other or anything else. There are gaps all around omega-3 fats. Therefore, every part of the cell membrane that is made of an omega-3 fat has space between the kinks that allow the exchange of nutrients and wastes across the membrane.

In addition to allowing each cell to “breathe”, ingest and excrete, omega-3 fats make cell membranes flexible. If you remember my description of how the heart and arteries expand and contract to pump the blood, you can appreciate how flexibility or the lack of it affects how well the arteries work.

Omega-3 fatty acids are also essential for brain function. All neurotransmitters are made from omega-3 fats. You literally cannot think, feel or function without omega-3 fats in your brain. Insufficient omega-3 fats is associated with low IQ, behavioral problems and many other conditions of the brain and nervous system. I consume them every day.

Tip number 15 Eat cold water fish, flax, chia and pastured animals, or eggs, butter, cheese, etc from pastured animals.

An oxidant that’s harder to avoid is Iron. We need Iron in our red blood cells to carry Oxygen. Iron is really great at carrying Oxygen because it has 4 open bonds. The problem is that too much Iron can cause oxidative damage to our blood vessels. How do we know this is true?

Women who are menstruating have a lower risk of heart attack than men of the same age until two years after they stop menstruating. This is still falsely used as a rationale for women to take female hormones after menopause. Men who are vegetarians such as Seventh Day Adventists have the same low risk of heart disease as menstruating women. It isn’t because they are taking female hormones. They aren’t eating meat. Meat has high levels of Iron. Men who eat meat but give blood 4 times per year have the same reduced risk of heart disease as menstruating women or vegetarian men. Get the picture? It’s the Iron. According to a study in the America Journal of Epidemiology, “blood donors had a 88% reduced risk of acute myocardial infarction compared with non-blood donors.” x

By the way, some of my patients use reddish colored salts like Himalayan or Celtic salt for it’s supposed health benefits. What makes the salt red or pink is Iron. Skip it unless you are menstruating and need Iron.

Tip number 16 Limit or avoid red meat. If you eat red meat, give blood.

Another source of inflammation is an amino acid called Homocysteine, a metabolite produced in the incomplete conversion of the amino acid Methionine to the amino acid Cysteine. If you have adequate amounts of Folic acid and Vitamin B6, the conversion of Methionine to Cysteine will be complete and you will not accumulate high levels of Homocysteine.

Why is elevated Homocysteine important? Homocysteine is easily oxidized and produces Superoxide and Peroxinitrite. These potent free radicals inhibit Nitric Oxide (more on Nitric Oxide later) and damage the endothelium (inner lining of the blood vessels). Elevated Homocysteine is also associated with apoptosis (death) of muscle cells adjacent to plaque, contributing to rupture and thromboembolism. Elevated serum Homocysteine is found in 40% of patients diagnosed with premature coronary artery disease or recurrent venous thrombosis.

Tip number 17 Make sure you have adequate levels of Vitamin B6 and Folic acid.

What else helps reduce Homocysteine? Get more of your protein from plants and less from meats. “High animal-protein diet was positively associated with high tHcy (Homocysteine) concentrations, whereas high plant-protein diet was inversely associated with tHcy concentrations” xi

Tip number 18 Eat less animal protein and more plant protein.

How do you know if you have high levels of Homocysteine?
There is an inexpensive blood test.
The optimal range is 10 – 12
Moderate elevation 15 – 30
Intermediate 30 – 100
Severe > 100

Nitric oxide

If I had to name a single molecule that is wonderful for the arteries, it would be Nitric Oxide. Why is that? Nitric Oxide dilates capillaries, delivering more blood to the heart and other muscles. This lowers blood pressure and allows the heart and skeletal muscles to produce more energy. The other great thing about Nitric Oxide is that it is an anti-oxidant that prevents the initiation of atherosclerosis. It does so by preventing foam cells from infiltrating the tunica intima. In other words, Nitric Oxide prevents oxidative damage to the inner lining of the blood vessels.

Where do we get it? Nitric Oxide is produced in the vascular endothelium (and also the oral cavity). This production is stimulated by thyroid hormone and also by exercise. The amino acid Arginine converts to Citrulline which converts to Nitric Oxide with the help of Folic Acid and Vitamin C. A high food source of Arginine is nuts. A high food source of Citruline is watermelon rind. You can also purchase nutritional supplements of Arginine and/or Citruline. Some of the better products come with Folic Acid and B12.

Some Nitric Oxide is also produced by bacteria in the oral cavity. Mouthwash kills the bacteria. Mouth breathing prevents inhalation of the Nitric Oxide. If you aren’t breathing through your nose, you are losing out on some of your Nitric Oxide. Check if you have a sinus infection or other airway obstruction.

The largest amount of Nitric Oxide is produced in the inner lining of your blood vessels and that production is driven by circulating levels of thyroid hormone. Production of thyroid hormone declines with age. Incidence of high blood pressure and atherosclerosis rises with age. Coincidence? Not likely. Improving thyroid health is covered in another article.

Something we can control is our level of exercise. Production of Nitric Oxide rises with exercise.xii This is one of the reasons exercise is so helpful in preventing cardiovascular disease.

Exposure to sunlight also causes the release of Nitric Oxide from our skin. A number of foods (notably beets) contain nitrites. These Nitric Oxide precursors are stored in the skin and converted to Nitric Oxide when exposed to ultraviolet light (UVA) from the sun. I have found my systolic blood pressure drop 15-20 points after less than 10 minutes of sun exposure. My rule of thumb for sun exposure is to only expose myself when my shadow is as long as I am tall. I also wear a hat to cover my face as my face is always getting at least indirect sun exposure.  Sunlight ages the skin and is a risk for melanoma and other skin conditions but is essential for producing Vitamin D and producing Nitric Oxide. I don’t use sunscreen as it gives a false sense of security and contains chemicals that according to the Environmental Working Group may be hazardous. I would rather wear a hat or long sleeves when in bright sun. In the winter or in the morning or late afternoon when the angle of the sun is low, I expose my body to the sun as it causes the production of melanin to the point of creating a tan, not a sunburn. The melanin in our skin is our best sunscreen.

Nitric Oxide is impaired by high levels of glucose or fructose.xiii As mentioned earlier, high levels of blood sugar cause advanced glycation end-products that destroy tissue and account for why diabetics have damage to their arteries, nerves, eyes and internal organs.xiv

So what can we do?

Tip number 19 Exercise at least 30 minutes per day, at least 5 days per week.
Tip number 20 Get adequate Folic Acid and Vitamin C.
Tip number 21 Eat nuts and/or take Arginine and/or Citrulline supplements.
Tip number 22 If you are a mouth breather, see and EENT and get your airway evaluated.
Tip number 23 Consider not using an alcohol based mouthwash.

How can you tell if you have high levels of inflammation?
There is a simple and inexpensive blood test called C-Reactive Protein or CRP. A slightly more expensive and accurate version of this test is called high sensitivity C-Reactive Protein or hCRP.

Tip number 24 Get tested for hCRP

What can you do for high levels of inflammation?
First of all, follow the steps listed above. If you still have too much inflammation, or if you just want to be proactive, try taking curcumin, the active ingredient in turmeric. You can take it as a supplement or as part of your daily diet. The best way to prepare it as a food is to heat turmeric in coconut oil with a little black pepper to increase absorption. Think South Asian cuisine. Saute turmeric, black pepper, garlic, chiles and other spices in coconut oil. Then add vegetables and meat or beans. It’s what’s for dinner! By the way, ginger is a related plant and has the same active ingredient. Making ginger tea or eating jerk sauce in Caribbean cooking has a similar effect.

Tip number 25 Take turmeric is you still have markers of inflammation.

I hope that this article empowers you to prevent disease and add years of health to your life. I know that what I have written can all seem overwhelming and technical. I put in a lot of detail so you can come back and get more later. You don’t have to do it all now. Take any one tip and make a change. The life you save could be your own.

David Wells, D.C., L.Ac.

i Zhang C, Rexrode KM, van Dam RM, Li TY, Hu FB. Abdominal obesity and the risk of all-cause cardiovascular, and cancer mortality: sixteen years of follow-up in US women.
iii Dietary Fructose Consumption Among US Children and Adults: The Third National Health and Nutrition Examination Survey. Medscape J Med. 2008; 10(7): 160. Published online 2008 Jul 9.
iv J Clin Invest. 2009 May;119(5):1322-34. doi: 10.1172/JCI37385. Epub 2009 Apr 20. Consuming fructose-sweetened, not glucose-sweetened, beverages increases visceral adiposity and lipids and decreases insulin sensitivity in overweight/obese humans.
v Glycemic Control and Coronary Heart Disease Risk in Persons With and Without DiabetesThe Atherosclerosis Risk in Communities Study
vi Glucose Levels and Risk of Dementia
Paul K. Crane, M.D., M.P.H., Rod Walker, M.S., Rebecca A. Hubbard, Ph.D., Ge Li, M.D., Ph.D., David M. Nathan, M.D., Hui Zheng, Ph.D., Sebastien Haneuse, Ph.D., Suzanne Craft, Ph.D., Thomas J. Montine, M.D., Ph.D., Steven E. Kahn, M.B., Ch.B., Wayne McCormick, M.D., M.P.H., Susan M. McCurry, Ph.D., James D. Bowen, M.D., and Eric B. Larson, M.D., M.P.H.
N Engl J Med 2013; 369:540-548August 8, 2013DOI: 10.1056/NEJMoa1215740
vii Bjornholt JV, Erikssen G, Aaser E, et al. Fasting blood glucose: an underestimated risk factor for cardiovasculardeath. Results from a 22-year follow-up of health nondiabetic men. Diabetes Care. 1999 Jan;22(1):45-9.
viii N Engl J Med. 2005 Oct 6;353(14):1454-62. Normal fasting plasma glucose levels and type 2 diabetes in young men. Tirosh A1, Shai I, Tekes-Manova D, Israeli E, Pereg D, Shochat T, Kochba I, Rudich A; Israeli Diabetes Research Group.
ix Bernstein AM, Roizen MF, Marintez L. Purified palmitoleic acid for the reduction of high-sensitivity C-ractive protein and serum lipids: a double-blinded, randomized, placebo controlled study. J Clin Lipidol. 2014;8(6):612-7
x Https://
xi Journal ListNutr Jv.12;2013PMC4176105
xii J Cardiovascular Risk. 1994 Aug;1(2):173-8
xiii Kimura C, Oike M, Koyama T, Ito Y. Impairment of endothelial nitric oxide production by acute glucose overload. Am J Physiol Endocrinol Metab. 2001 Jan;280(1):E171-8
xiv Vlassara H. Advanced glycation end-products and atherosclerosis. Ann Med. 1996 Oct;28(5):419-26.

Nutrition and Osteoporosis

Nutrition and Osteoporosis

What You Need To Know (and maybe a little more).

I am frequently asked, “Do I need to take calcium supplements to keep my bones strong?” The short answer is “probably no”, but I wish to take this opportunity to give a more thorough answer than “yes” or “no”. I believe in empowering you with the knowledge to take care of yourself. So here’s the long answer (If you are short of time, skip to the recommendations section at the end).

While it is true that bones contain much of the calcium in our bodies, and it is also true that bones tend to lose calcium and become weaker and more prone to fracture with age, it is not true that our bones fracture because of a lack of calcium. If you were to grind up a calcium tablet, you would hold a soft pile of powder in your hand. What gives bone structural integrity and flexibility, is the matrix of connective tissue and living cells that holds the calcium in place. Calcium by itself is like bricks without mortar.

Anatomically, bones are composed of:
1. The very hard outer surface (periosteum),
2. The fairly hard material that makes up the bulk of the bone (compact bone),
3. The softer inner marrow where blood cells and immune cells are made.

Bone is about one-third living cells. The rest is calcium phosphate, calcium carbonate and other minerals embedded in a mesh of tough, dense connective tissue. Though the other minerals make up a smaller proportion of the total mineral content in bone than does calcium, they are, nonetheless, essential. We are only as strong as our weakest link.

Why should we care about our bones? Thin bones (osteopenia) and porous bones (osteoporosis) are at greater risk of fracture than healthy bones. The National Osteoporosis Foundation says that “osteoporosis causes more than 1.5 million fractures annually: 700,000 vertebral, 300,000 hip, 250,000 wrist and 300,000 fractures at other sites”.i Furthermore, “an average of 24 percent of hip fracture patients aged 50 and over die in the year following their fracture.”ii Our bones reach their maximum strength in our early twenties and decline steadily every year thereafter.

Back to calcium. Yes, calcium is an important component of bone, but it is only necessary to supplement calcium if your diet is deficient in calcium relative to your needs. You may have read that the Recommended Daily Allowance (RDA) for calcium set by the United States government is 1,200 mg per day for women. However, a Swedish study of 61,433 women over a period of 19 years found that those taking 750 mg per day of calcium had the lowest risk of fracture. Increasing calcium intake beyond 750 mg did not confer additional benefit and in fact was associated with increased risk of fracture!iii A pregnant or lactating woman may need to take supplemental calcium because her need is high, but the average person eating a varied, whole-food diet should not need supplemental calcium. Of course, it is true that most Americans aren’t eating a varied, whole-food diet but even so, the calcium that comes in food is generally better absorbed than the calcium that comes in pills. Therefore, it is far better to change your diet than to take a pill.

Speaking of pills, most calcium pills are made from ground-up limestone. This is calcium carbonate from shells of ancient sea life that piled up on the ocean floor. Over millions of years of tons of compressive force these shells became the white cliffs of Dover or the Dolomite mountains. A lot of stomach acid is required to break down and absorb this form of calcium. This last fact is why “Tums” is such a terrible way to supplement calcium. The large amount of calcium in Tums neutralizes stomach acid, preventing absorption.

Just to expand on that topic for a moment, stomach acid declines as we ageiv. Could this be the reason for osteoporosis? Yes, lack of stomach acid does cause osteoporosis. That’s why people taking proton pump inhibitors to reduce acid reflux suffer from more spinal fractures than the average person.v It is likely why osteoporosis is more common as we age. It is also why many traditional cultures start the meal with an appetizer that stimulates the production of acid.

So Tip Number 1 is to eat whole foods in a relaxed, slow manner, following the customs of almost any traditional culture (starting the meal with appetizers that are sour, bitter or spicy).

Eating this way may also eliminate the need for the drugs to reduce acid reflux. Wait a minute! Stimulating acid production reduces acid reflux?

A curious thing about stomach acid is that the symptoms of “acid reflux” or GERD are actually caused by low acid, not by the high acid that most people assume is the cause. Adequate stomach acid is needed to close the ring of muscle (cardiac sphincter) that separates the stomach from the tube leading to it (the esophagus). Insufficient stomach acid (or simply eating too much) allows the food to push up into the esophagus. The esophagus cannot tolerate even a low amount of acid and so it will burn on contact with the mildly acidic food. This is how low stomach acid causes heartburn.

Hydrochloric acid (stomach acid) is of course needed to digest our food. Without it, we cannot digest and absorb protein, calcium, Vitamin B12 or a host of other nutrients. Hydrochloric acid is also needed to kill bacteria and other pathogens in the food. That’s why people on drugs to reduce stomach acid (proton pump inhibitors) are more likely to get pneumoniavi. One study found that 33,000 deaths a year are due to pneumonia acquired as a result of taking acid-reducing proton pump medicationsvii.

An even more important pathogen that flourishes in the stomach when there is insufficient acid is Helicobacter Pylori (known as H. pylori for short). Overgrowth of H. pylori due to insufficient stomach acid is the cause of stomach ulcers, gastritis, reflux, GERD and esophageal cancer.viii How common is this? It is estimated that 20 percent of individuals under the age of 40 are infected with H. pylori and 50 percent to 60 percent of individuals over the age of 60 are infected.ix Wow! That is really common. Remember, taking drugs that reduce stomach acid actually increases the risk of H. pylori infection, which in turn increases the risk of reflux, GERD, esophageal cancer, osteoporosis and pneumonia.

By the way, I noted earlier that low stomach acid impairs the absorption of Vitamin B12x. Lack of B12 is implicated in Alzheimer’s disease and heart diseasexi. Add that to the list of reasons to take care of your stomach without relying on anti-acid drugs. To learn more, read Your Bones: How You Can Prevent Osteoporosis & Have Strong Bones for Life Naturally by Lara Pizzorno and Jonathan Wright, M.D.

So, if you have enough calcium in your diet, how do you get it to become bone? I have seen many x-rays of patients whose bones in the lower back look osteoporotic, but their abdominal aorta looks calcified. The calcium that should be in the bones is not in the bone, but is in the blood vessels instead. Taking more calcium, without directing where it goes will only worsen the hardening of the arteries and stiffness in the muscles. This situation is more common than you would think. Plenty of calcium, but it is in the wrong places.

The arrows in the x-ray above are pointing to the abdominal aorta. It should not be visible. The reason we can see it is that it is calcified.

How does this happen? In addition to its role in bone, calcium helps nerves and muscles fire faster and stronger. When we are alert and active, calcium is drawn from the bones and directed to the soft tissues to help with these vital functions. The movement of calcium from the bones to the soft tissues is accomplished with the help of “fight or flight” hormones. At the end of the day, we are supposed to relax and let the “rest and digest” hormones (principally calcitonin from the thyroid gland) put the calcium back in the bones. That way, we rest comfortably at night (no twitching muscles or disturbed sleep). Picture for a moment, a traditional hunter-gatherer, farmer or laborer. Most of the day was consumed with routine physical activities. Probably a lot of sunlight, as these labors took place out doors. At night, a little story around the campfire after dinner for the hunter-gatherer, perhaps reading a book or having a nice conversation before going to bed in more recent times. How does this compare to our modern lives? We wake up to an alarm clock, grab some caffeine on the run, suffer high-stress all day, which we continue into the night with late emails, bills to pay and perhaps some graphic violence on the evening news before falling exhausted into bed. When are those “rest and digest” hormones going to be stimulated? The fight or flight hormones are turned on all the time. We can live life in the fast lane, but where are we going?

Tip Number 2: stop all work activities and overly stimulating television by dinnertime. Reconnect with your spouse. Read a book. Take a walk after dinner. Get creative. This is a time to nurture yourself and relax.

Let’s take a look at the effect of our ancestor’s labors on their bone density. The hard physical work of hunting or farming stresses and compresses the bones, stimulating the bone-forming cells (osteoblasts) to make more bone. That is why exercise is recommended to prevent osteoporosis (More on that later). As a rule, most of our ancestor’s work was done outdoors. Sun exposure causes the body to make Vitamin D in the skin, which helps move calcium into the bones, making the bones stronger. How much Vitamin D does a person make in their skin? Vacationers in Hawaii make 10,000 to 25,000 units of vitamin D in their skin per day.xii How much is that compared to what we normally get? The National Health and Nutrition Examination Survey found that over fifty million children and adolescents are getting below the recommended daily requirement of vitamin D.xiii How much is recommended? The United States government says that the Recommended Daily Allowance is 600 units. If that sounds low to you, that’s because it probably is. Research shows that an adequate supplemental intake to achieve optimal serum levels is a little over 2,000 IU’s per day.xiv

How can you know the right amount for you? There is a blood test for vitamin D that you can take to find out if you are deficient. You want to score on the high end of normal because even within the normal range, there is a strong correlation between lower (though still normal) levels of vitamin D and a host of diseases, including colon and breast cancer, xv xvi multiple sclerosis, Alzheimer’s, Parkinson’s disease, schizophrenia, diabetes, autoimmune disorders, hypertension, atherosclerosis and muscle weakness.xvii It is best to be sure that you have plenty of D, but not too much.xviii There is an optimal dose for you.

Tip Number 3 Take the blood test to check your vitamin D levels.

Is sunlight a safe way to get vitamin D? Yes, but only in the early morning or late afternoon. The sun’s rays can cause free-radical damage to your skin. Damage to the collagen in skin causes wrinkles. Damage to the DNA of skin cells can cause skin cancer. The cancer-causing rays are diminished by passing through the atmosphere. In the early morning or late afternoon, or midday during the winter, the sun’s rays are weakened by passing through more atmosphere than during the middle of a summer day. Melanin in the skin (the pigment that gives our skin color) is an antioxidant that protects against skin cancer. In other words, having a tan is protective. Eating fruits and vegetables that are rich in colorful antioxidants also protects against free-radical damage from the sun. Sunscreen unfortunately does not provide protection. After 20 to 30 minutes, the protective chemicals in sunscreen actually become free-radicals themselves.xix Furthermore, they provide a false sense of security, leading people to stay out in the sun longer than is safe. I recommend wearing a hat to protect the face and neck while getting some early morning or late afternoon sun to gradually build a tan. Stay out of the sun during the middle of the day or wear protective clothing and a broad-brimmed hat.

Tip Number 4 Get sunlight safely, several times a week if possible.

What about dietary sources of vitamin D? The highest food sources are oily fish such as salmon and swordfish, with lesser amounts in sardines, tuna and other fish. Unfortunately, those top predator fish contain large amounts of mercury.xx This is especially true of swordfish. Sardines have much lower levels of mercury because they aren’t so high on the food chain. There is some Vitamin D in meat, milk and eggs, but not very much. Land animals aren’t nearly as good a source because they are mainly composed of saturated fats and cholesterol, while the fish oil sources are very high in essential omega-3 fatty acids. These omega-3 fats are necessary to reduce blood pressure and risk of heart disease,xxi as well as improving cognitive function. The food source I recommend is Nordic Naturals cod liver oil, because it is certified mercury free.

Tip Number 5 Take one tablespoon of cod liver oil daily. In addition to providing essential omega-3 fatty acids, cod liver oil contains 1,360 IU’s of Vitamin D per tablespoon.xxii

What about all the hard work our ancestors performed? How does that help? Everyone knows that weight-bearing exercise is necessary to build and maintain bone.xxiii Why is that? The answer is that bone is continually remodeled by two types of cells. One of the cells continually eats bone. These are called osteoclasts. The other type of cell continually makes new bone. These are called osteoblasts. The eaters keep nibbling away all the time. Kind of like the adage, “Rust never sleeps”. The blasts (builders) work in response to electrical impulses created by compression on the bone. For instance, if you are walking, the compressive forces on the bones of your legs, hips and spine stimulates the blasts to make those bones stronger. To maintain the strength of bones in the arms, weight-lifting or pushups may be needed. The beauty of the way these cells work is that the bone is continually remade to serve the functions we do every day. If you were to lie in bed for an extended period of time, your bones would become weaker. It’s as if your body is saying, “If you don’t need that calcium in the bone, we’ll just use it for something else”. The body is very economical. It doesn’t maintain tissue that you aren’t using. Our bodies are active, dynamic processes, not things. We are verbs, not nouns.

This process works to our advantage. If we break a bone and it sets crooked, the “blasts” will keep strengthening where the compressive forces are and the “clasts” will keep eating the parts where there is no functional stress. This will eventually remodel the bone to become straight. (By the way, the only tissues the body keeps that are not functional are scar tissue and fat. This is because these tissues do not require energy to be maintained.)

Tip Number 6 Perform weight-bearing exercise at least three times a week.

I mentioned caffeine above. Caffeine acts like a fight or flight hormone. Drinking coffee and to a lesser extent, tea or decaf, is like taking liquid stress hormones. Caffeine moves calcium from your bones to your soft tissues. Caffeinated soft drinks are even worse. Not only do they contain caffeine and diabetes-inducing amounts of sugar, but they also have phosphoric or carbonic acid, which is what makes them fizzy. These acids dissolve calcium. If you have a child’s discarded tooth available, try dropping it into a coke and see what happens. It will dissolve and disappear pretty quickly. Tip Number Seven: Stay away from coffee and sodas.

What about drugs to strengthen bone? The bisphosphonate drugs (such as Fosomax, Boniva, etc.) commonly prescribed to treat or prevent osteoporosis work by killing osteoclasts. These drugs were originally developed to treat a kind of bone cancer called Paget’s Disease, which is a form of cancer involving over-production of osteoclasts. In other words, these drugs were a form of chemotherapy. Their half-life is ten years.xxiv In other words, ten years after taking one of these drugs, half of it is still in your system. “Okay,” you say. “So these are strong medicines. Why not take them? So what if they kill off the bone-destroying osteoclasts. What’s wrong with that?”

The problem with killing off the osteoclasts is that they are necessary for bone health. One of the functions the “clasts” perform is to keep the canals in the bone open so nutrients and wastes from the living cells in bone can flow freely. Without osteoclasts, the bone gradually becomes harder and more brittle because it is dying.xxv The bone looks better on a bone density test because it has a higher mineral content. Initially, a low dose of the drug may be helpful but continued use of bisphosphonates does not give increased benefits.xxvi The bone density test provides a false sense of reassurance at your annual physical, but harder is not always better. To get a sense of what I am talking about, imagine trying to break the “wishbone” of a turkey on Thanksgiving Day. The bone is so flexible, it is very hard to break. Wait a few days for the bone to dry out and it snaps easily. A dead bone is more brittle than living tissue. The osteoclasts that are killed by bisphosphonate drugs are needed for healthy bone remodeling. This is well stated in the Journal of Endocrinology and Metabolism, “Microcracks occur in normal bone after the kind of stresses encountered in day-to-day life. These cracks are detected by the osteocytes, which initiate a bone-remodeling unit to repair the damage. If bone resorption is strongly inhibited, the damage can’t be repaired because the osteoclasts won’t dissolve the bone.”xxvii Imagine you need to remodel your kitchen but you can’t take out the old cabinets or flooring. Putting more cabinets on top of the old ones doesn’t make sense, but that’s what you get with bisphosphanate drugs.
This bone weakening is not just theoretical. A known side-effect of bisphosphonate drugs is “osteornecrosis of the jaw”. Let’s break down that word. “Osteo” means bone. “Necrosis” means death. It is reportedly rare but I have seen two cases among my patients. Dentists I have talked with report they have seen it as well. A study in the Journal of Oral Maxillofacial Surgery reported that while most cases were due to high intravenous doses of bisphosphonates for cancer therapy, some were due to long-term oral use for osteoporosis.xxviii

Tip Number 8 Seriously question your doctor about your need for bisphosphonate drugs if they are prescribed.

I mentioned earlier that calcium isn’t the only material that makes up bone. Trace elements and other nutrients are needed to make and strengthen bone. Chief among these minerals is magnesium. Magnesium is the third most abundant mineral in your body and a very important element in bone. Trace elements needed for healthy bone formation include boron, strontium and silicon (More on these in a moment).

Magnesium is found in chlorophyll, so any colorful vegetable or fruit provides magnesium. Magnesium does compete with calcium for absorption, so excessive amounts such as found in laxatives can be harmful to calcium levels. Does magnesium increase bone density? Yes it does. One study showed a 1 to 8 percent rise in bone density when taking magnesium supplements.xxix Other studies show that severe magnesium deficiency “causes impaired bone growth, osteopenia and skeletal fragility.” xxx The average American diet is deficient in magnesium but then again, it is deficient in most nutrients. Once again, eat whole foods. I also suggest taking supplemental magnesium. I have been taking 200 mg magnesium gluconate twice a day since the early 1980s. It keeps my mind calm and muscles relaxed. How much should you take? Your body can only absorb so much magnesium at a time from your intestines. If you take more that what you need, the magnesium remaining in your intestines will attract water to itself and pass as loose stools or diarhea. Many clinicians recommend taking just short of that effect to find the optimal dose.

Magnesium is also great for insomnia. It helps prevent restless leg syndrome, muscle cramps, heart palpitations and of course constipation. Please note that magnesium is needed by your body to convert Vitamin D to the active form. If you increase your Vitamin D intake, you may need to increase your magnesium intake as well or you could suffer heart palpitations from magnesium deficiency.

Tip Number 9 Take magnesium citrate or gluconate (not oxide) 200 to 400 mg per day, or up to bowel tolerance.

Boron stimulates bone forming cells (osteoblast) and inhibits bone destroying cells (osteoclasts).xxxi Boron stabilizes and extends the half-life of vitamin D and estrogen.xxxii Furthermore, post-menopausal women who took 3 mg supplemental boron per day showed improved retention of calcium and magnesium in their kidneys.xxxiii Three milligrams isn’t much, but about half the population of the United States gets less than 1 mg boron per day.xxxiv Boron is found in raisins, almonds, hazel nuts, avocado, cashews, dates, peanut butter, Brazil nuts, walnuts, dried apricots, red kidney beans and many other foods.xxxv

Strontium is a trace element that has been proven to be very beneficial in preventing and treating osteoporosis. A research study published in the Journal of Clinical Endocrinology and Metabolism found a “39 percent reduction in vertebral fractures and a 36 percent risk reduction in hip fracture in post menopausal women over a 3-year time period. Bone mineral density increased 8.2 percent at the femoral neck and 9.8 percent at the hip.”xxxvi Strontium ranelate has been patented in Europe as a drug but is available over the counter as a nutritional supplement in this country, usually as strontium citrate or gluconate. It competes with calcium for absorption so is best taken at a different meal. Foods high in strontium include, whole grains, seafood, poultry, meats, vegetables and legumes.

Another mineral of interest is silicon. Studies have shown that 40 mg a day of dietary silicon or more is associated with increased bone density.xxxvii The average daily intake for women is around 18 mg. It is higher for men on average because it is contained in beer and men drink more beer. Before you think I’m advocated drinking a lot of beer, let me note that dietary sources include whole grains, carrots and green beans.

In addition to Vitamin D3 (the “Sunshine Vitamin”), there is another vitamin critical to bone health. That vitamin is K2 or menaquinone. This nutrient is very exciting because it not only helps to build bone, it does so by removing calcium from arteries and other places where it is causing problems. It is so effective in reducing plaque in the arteries that a 10-year study of 4,800 fifty-five-year-olds found that vitamin K2 reduced cardiac deaths by 50 percent and “all cause mortality” by 25 percent. This research is known as the Rotterdam Studyxxxviii. This correlates well with a Japanese study that found Vitamin K2 is effective as drugs in preventing osteoporotic fractures.xxxix Additionally, Vitamin K2 has been found to reduce risk of prostate cancer by 35 percentxl, Non-Hodgkins Lymphoma by 45 percentxli and hepatocellular carcinoma by 20 percentxlii.

How do you get K2? The highest food source is a Japanese food called natto. It is a slimy fermented soybean dish that I tried once (and will never try again). It is also found in fermented curds, cheeses, fish and high fat meats, dairy and eggs from pasture-raised animals. The lowest levels of Vitamin K2 were found in people who consumed the most polyunsaturated fatty acids (such as Canola oil). Smokers had the very lowest levels of K2, regardless of what they ate. The FDA recommends 90 mcg (micrograms) for women and 120 mcg for men, but researchers treating cancer have used doses as high as 45 mg (that’s 45,000 mcg) per day with good results and no side effects.xliii

I am currently taking liquid Vitamin K2 from Thorne Research. Each drop is 1 mg (1,000 mcg). I find it the easiest way to take K2, especially since I don’t eat a lot of high fat meats, cheeses or natto. Tip Number Ten: Take one drop of Thorne Vitamin K2 per day.

There is a blood test that indirectly measures Vitamin K2 deficiency. It is called uncarboxylated osteocalcin. It is a direct measure of how well the body is forming bone. However, since there appears to be no downside for overdosing Vitamin K2, I recommend taking at least 1 drop of the liquid Vitamin K2 from Thorne Research.

So in summary,
1. Eat a variety of whole foods in a relaxed manner. Use appetizers and seasonings that stimulate your appetite.
2. Take a walk or engage in another relaxing activity after dinner.
3. Get tested for your blood level of Vitamin D.
4. Get some late afternoon or early morning sunshine. Wear a hat rather than sunscreen.
5. Take one tablespoon of cod liver oil per day.
6. Do weight-bearing exercise at least three times a week.
7. Avoid coffee and carbonated beverages.
8. Question any recommendation to take bisphosphonate drugs, particularly more than a few years.
9. Consider taking 200 – 400 mg magnesium gluconate or citrate per day.
10. To get boron, strontium, silicon and other nutrients, eat whole foods. Remember, real food doesn’t have ingredients. If your grandmother wouldn’t recognize it, it isn’t food. This may require more money, time and effort (such as going to the Farmer’s Market and learning to cook from scratch, but it is worth it. The extra money will be saved in doctors bills and the extra time spent will be regained in years of good health).
11. Take one drop per day of Thorne Vitamin K2.

I hope you found this article informative and useful. I apologize if it is too technical, but I want to be accurate and I trust you have the intelligence to understand it. Thank you for reading it through.

Warmest regards,
David Wells, D.C., L.Ac., MS Nutrition

iii Dietary calcium intake and risk of fracture and osteoporosis: prospective longitudinal cohort study
BMJ 2011; 342 doi: (Published 24 May 2011)
Cite this as: BMJ 2011;342:d1473
iv Assessment of gastric acidity of Japanese subjects over the last 15 years. Morihara M, Aoyagi N, Kaniwa N, Kojima S, Ogata H. Biol Pharm Bull. 2001 Mar;24(3):313-5.
National Institute of Health Sciences, Tokyo, Japan.
v Laura E. Targownik, MD MSHS, Lisa M. Lix, PhD, Colleen J. Metge, PhD, Heather J. Prior, MSc, Stella Leung, Msc. and William D. Leslie MD
Use of proton pump inhibitors and risk of osteoporosis-related fractures CMAJ August 12, 2008 179:319-326; doi:10.1503/cmaj.071330
vi Chun-Sick Eom, Christie Y. Jeon, Ju-Won Lim, Eun-Geol Cho, Sang Min Park and Kang-Sook Lee. Use of acid-suppressive drugs and risk of pneumonia: systematic review and meta-analysis. CMAJ, December 20, 2010 DOI: 10.1503/cmaj.092129
vii JAMA. 2009 May 27;301(20):2120-8. Acid-suppressive medication use and the risk for hospital-acquired pneumonia. Herzig SJ, Howell MD, Ngo LH, Marcantonio ER.
viii Kusters JG, van Vliet AH, Kuipers EJ (July 2006). “Pathogenesis of Helicobacter pylori Infection”. Clin Microbiol Rev 19 (3): 449–90.
xi J Alzheimers Dis. 2010;19(2):481-8. Vitamin B12 levels in Alzheimer’s disease: association with clinical features and cytokine production. Politis A, Olgiati P, Malitas P, Albani D, Signorini A, Polito L, De Mauro S, Zisaki A, Piperi C, Stamouli E, Mailis A, Batelli S, Forloni G, De Ronchi D, Kalofoutis A, Liappas I, Serretti A.
xii Holick, MF (1995). Environmental factors that influence the cutaneous production of vitamin D. Am. J. Clin. Nutr. 61 (3 Suppl): 638S–645S.
xiii Pediatrics. 2009 Sep;124(3):e362-70. Epub 2009 Aug 3.
Prevalence and associations of 25-hydroxyvitamin D deficiency in US children: NHANES 2001-2004. Kumar J, Muntner P, Kaskel FJ, Hailpern SM, Melamed ML. Children’s Hospital at Montefiore, Bronx, New York, USA.
xiv Heany R. The vitamin D requirement in health and disease. J Steroid Biochem Mol Biol. 2005;97:13–9. [PubMed]
xv Ann N Y Acad Sci. 1999;889:107-19. Calcium and vitamin D. Their potential roles in colon and breast cancer prevention. Garland CF, Garland FC, Gorham ED. Department of Family and Preventive Medicine, University of California, San Diego 92093, USA.
xvi Lappe JM, Travers-Gustafson D, Davies KM, et al. Vitamin D and calcium supplementation reduces cancer risk: Results of a randomized trial. American Journal of Clinical Nutrition 2007; 85(6):1586–1591.
xvii Tuohimaa P, Keisala T, Minasyan A, Cachat J, Kalueff A (December 2009). “Vitamin D, nervous system and aging”. Psychoneuroendocrinology 34 (Suppl 1): S278–86.
xviii Hsu, J. J.; Tintut, Y.; Demer, L. L. (2008). “Vitamin D and Osteogenic Differentiation in the Artery Wall”. Clinical Journal of the American Society of Nephrology 3 (5): 1542–7.
xix Free Radic Biol Med. 2006 Oct 15;41(8):1205-12. Epub 2006 Jul 6. Sunscreen enhancement of UV-induced reactive oxygen species in the skin. Hanson KM, Gratton E, Bardeen CJ. Department of Chemistry, University of California at Riverside, Riverside, CA 92506, USA.
xxi Current Opinion in Clinical Nutrition & Metabolic Care: March 2007 – Volume 10 – Issue 2 – p 129-135 Lipid metabolism and therapy
xxii NIH Office of Dietary Supplements Dietary Supplement Fact Sheet: Vitamin D. 2009/11/13;
xxiii Bull World Health Organ. 2003;81(11):827-30. Epub 2004 Jan 20.
Exercise interventions: defusing the world’s osteoporosis time bomb. Kai MC, Anderson M, Lau EM. Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Hong Kong, SAR, China.
xxiv Ensrud KE, Barrett-Connor EL, Schwartz A, Santora AC, Bauer DC, Suryawanshi S, Feldstein A, Haskell WL, Hochberg MC, Torner JC, Lombardi A, Black DM 2004 Randomized trial of effect of alendronate continuation versus discontinuation in women with low BMD: results from the Fracture Intervention Trial long-term extension. J Bone Miner Res 19:1259–1269
xxv Currey JD 1984 Effects of differences in mineralization on the mechanical properties of bone. Philos Trans R Soc Lond B Biol Sci 304:509–518
xxvi Bone. 2004 Apr;34(4):599-604. Changes in bone mineral density explain little of the reduction in vertebral or nonvertebral fracture risk with anti-resorptive therapy. Delmas PD, Seeman E. Claude Bernard University of Lyon and INSERM Research Unit 403, Lyon, France.
xxvii Ott, Susan. The Long-Term Safety of Bisphosphonates. The Journal of Clinical Endocrinology & Metabolism March 1, 2005 vol. 90 no. 3 1897-1899
xxviii J Oral Maxillofac Surg. 2004 May;62(5):527-34. Osteonecrosis of the jaws associated with the use of bisphosphonates: a review of 63 cases. Ruggiero SL, Mehrotra B, Rosenberg TJ, Engroff SL. Division of Oral and Maxillofacial Surgery, Long Island Jewish Medical Center, New Hyde Park, NY 11040, USA.
xxix Magnes Res. 1993 Jun;6(2):155-63. Trabecular bone density in a two year controlled trial of peroral magnesium in osteoporosis. Stendig-Lindberg G, Tepper R, Leichter I. Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Israel.
xxx J Am Coll Nutr. 2009 Apr;28(2):131-41. Skeletal and hormonal effects of magnesium deficiency. Rude RK, Singer FR, Gruber HE. USC Keck School of Medicine, Los Angeles, CA.
xxxi Therapeutic effect of dietary boron supplement on retinoic acid-induced osteoporosis in rats. Xu P, Hu WB, Guo X, Zhang YG, Li YF, Yao JF, Cai QK. Department of Orthopedics, Xi’an Red Cross Hospital, Xi’an 710054, China.
xxxii Volpe S, Taper LJ, Meacham S. The relationship between boron and magnesium status and bone mineral density in the human a review. Magnes Res. 1993;6(3 ):291–6. [PubMed]
xxxiii Nielsen F. Studies on the relationship between boron and magnesium which possibly affects the formation and maintenance of bones. Magnes Trace Elem. 1990;9(2 ):61–9. [PubMed]
xxxiv National Academy of Sciences. A Report of the Panel on Micronutrients. Dietary reference intakes for vitamin A, vitamin K, arsenic, boron, chromium, copper, iodine, iron, manganese, molybdenum, nickel, silicon, vanadium, and zinc. Washington DC: National Academy Press; 2001.
xxxvi J Clin Endocrinol Metab 2005 May;90(5):2816-22. Epub 2005 Feb 22.
Strontium ranelate reduces the risk of nonvertebral fractures in postmenopausal women with osteoporosis: Treatment of Peripheral Osteoporosis (TROPOS) study, Reginster, et al
xxxvii J Bone Miner Res. 2004 Feb;19(2):297-307. Epub 2003 Dec 16.
Dietary silicon intake is positively associated with bone mineral density in men and premenopausal women of the Framingham Offspring cohort. Jugdaohsingh R, Tucker KL, Qiao N, Cupples LA, Kiel DP, Powell JJ. Gastrointestinal Laboratory, The Rayne Institute, St Thomas’ Hospital, London, United Kingdom.
xxxviii Dietary Intake of Menaquinone is Associated with a Reduced Risk of Coronary Heart Disease: The Rotterdam Study. J. Nutr. November 1, 2004 vol. 134 no. 11 3100-3105
xxxix J Bone Miner Res. 2000 Mar;15(3):515-21.Vitamin K2 (menatetrenone) effectively prevents fractures and sustains lumbar bone mineral density in osteoporosis. Shiraki M, Shiraki Y, Aoki C, Miura M. Research Institute and Practice for Involutional Diseases, Nagano Prefecture, Japan.
xl Am J Clin Nutr. 2008 Apr;87(4):985-92. Dietary intake of vitamin K and risk of prostate cancer in the Heidelberg cohort of the European Prospective Investigation into Cancer and Nutrition (EPIC-Heidelberg). Nimptsch K, Rohrmann S, Linseisen J. Division of Cancer Epidemiology, German Cancer Research Centre, Heidelberg, Germany.
xli Vitamin K may reduce cancer risk: EPIC study. JAMA. 2004 Jul 21;292(3):358-61.
xlii Vitamin K may reduce cancer risk: EPIC study JAMA. 2004 Jul 21;292(3):358-61.
xliii Habu D, Shiomi S, Tamori A, Takeda T, Tanaka T, Kubo S, Nishiguchi S. Role of vitamin K2 in the development of hepatocellular carcinoma in women with viral cirrhosis of the liver. JAMA, 2004 Jul 21;292(3):358-61.