Tag: Nutrition

Take Care of Your Thyroid – Part Two – Hyperthyroidism

So what exactly is hyperthyroidism?

Your thyroid gland produces a hormone (thyroxin) that sensitives all your cells to the metabolism stimulating effects of adrenal hormones. You can think of thyroid hormone as your body’s metabolic cruise control system. It sets the speed of your metabolism, from how warm you are to how fast your heart beats. While adrenalin comes and goes in spurts, thyroid hormone sets the long-term tempo. Normally, your thyroid gland produces just the right amount of hormone. Hyperthyroidism is an over-production of thyroid hormone, causing an increase in temperature, heart rate, muscle contraction and nerve firing. Too much thyroid hormone therefor causes rapid, irregular pulse rate, low grade fever, muscle trembling, anxiety or panic, irritability and fits of rage. Imagine drinking a whole pot of espresso. It’s not fun. Furthermore, it puts a stress on your heart.  Hyperthyroidism is classified into several types: 

Grave’s disease, 

Hyperfunctioning thyroid nodules (Toxic Thyroid Adenoma and Toxic Multinodular Goiter) and 

Thyroiditis (Hashimoto’s, post-partum and subacute or DeQuervain’s). 

All of these conditions are forms of thyroid autoimmune disease, meaning that your immune system has attacked your own thyroid.  Taken together, thyroid autoimmune diseases affect 7-8% of the population, totaling up to 24 million people in the United States, up to 10% of women and 3% of men.  In other words, hyperthyroidism is a relatively common condition, particularly in women. I also suspect it is under diagnosed for reasons you will read later.

Grave’s disease

At 70 to 80% of all cases of hyperthyroidism, Grave’s disease is the most common form of the disease.  It occurs most frequently in women over the age of 20, occurring in about 2% of this demographic.  

Grave’s disease is an autoimmune disorder.  More than 85% of all autoimmune patients are female.  As part of a broader trend, the incidence of autoimmune disease in general is estimated to be between 14.7 and 23.5% of the population and that incidence is rising.   This increasing incidence is very likely to be due to environmental toxins.

What are the symptoms of Grave’s disease?

Fever, heat intolerance, nervousness, anxiety, insomnia, fits of rage, sweating, tremor, heart palpitations, rapid heart rate and profound fatigue.  In women, menses are scant and infrequent.

Objective signs include fever and an elevated resting heart rate.  I have measured a heart rate of over 120 beats per minute in a patient who was resting in bed.  This went on for a few weeks accompanied by a fever of 99 to 100 degrees.  Even to stand up is exhausting when the body is working that hard to raise metabolism.  As opposed to fever caused by infection where the patient wants to get under the covers and stay warm, in Grave’s disease, the patient has heat intolerance and throws off the sheets.  Sweating occurs to dissipate heat.  In some cases, the patient may also exhibit protruding eyes (exophthalmos).  Swelling of the thyroid gland (goiter) is common in Graves disease. The lack of these signs does not rule out thyroid disease.

Hyper-functioning thyroid nodules (Also known as Toxic Thyroid Adenoma and Toxic Multinodular Goiter)

There are several kinds of thyroid nodules.  They differentiated by whether or not they are actively producing hormones and also by their composition.  Some nodules are mere fluid filled cysts.  Others are filled with a colloid.  The nodules that produce symptoms are doing so because they are producing extra thyroid hormones.  These hyper-functioning thyroid nodules produce symptoms of hyperthyroidism as discussed above.

How are nodules detected?  In a physical exam, the doctor stands behind you and feels the thyroid with his or her fingertips.  The thyroid gland is wrapped around the trachea (windpipe), in the hollow just above the sternum. In a normal person, the thyroid is barely detectable and feels equal when comparing right and left sides.  A nodular thyroid feels lumpy or asymmetrical.  Nodules are generally non-tender, the exception being de Quervain’s thyroiditis. 

Rule out thyroid cancer

While the incidence of thyroid cancer is low, the consequence of failing to detect it early is high.  Only about 5% of palpable thyroid nodules are cancerous.  The warning sign in palpation is that the lump feels hard and attached to deeper tissues.   Your doctor will order other tests if a lump feels suspicious.

Hashimoto’s thyroiditis

Hashimoto’s is a chronic, sub-acute autoimmune destruction of the thyroid gland.  

Hashimoto’s is harder to diagnose because symptoms of Hashimoto’s thyroiditis are symptoms of low thyroid function, namely fatigue, weight gain, low temperature/intolerance to cold, dry skin and hair, frequent heavy menstrual periods, hoarseness and lack of mental clarity. Many doctors do not check for the autoimmune component and just treat it as hypothyroidism.

Goiter is the usual clinical finding in Hashimoto’s, with the thyroid commonly though not always, being 2-3 times it’s normal size.  

Post-partum Thyroiditis

The stresses of pregnancy, childbirth, nursing and early childcare can induce thyroiditis in susceptible women.  Typically, an episode of hyperthyroidism occurs 2-6 months post-partum and resolves without treatment within a year.  About a quarter of these women develop hypothyroidism four or more years later.

Regarding pregnancy, sub-clinical hypothyroidism does not reduce rates of conception but does increase the rate of spontaneous abortion.

Sub-Acute or DeQuervain’s thyroiditis

The etiology of de Quervain’s is thought to be a viral infection.  Being an acute inflammatory condition, the thyroid nodules are tender to palpation.  The thyroid is generally asymmetrically enlarged and firm.  

Symptoms of de Quervain’s are hyperthyroid symptoms while the infection is raging, followed by symptoms of hypothyroidism when the autoimmune damage is done.   Fever can range from 100 to 101 degrees F.  Symptoms may include neck, jaw, throat and ear pain.  It is often confused with upper respiratory or dental infection in the early stages and in fact is often a sequel to an upper respiratory infection.  There may be pain with swallowing or turning the head.   Patients with de Quervain’s are more likely to be profoundly fatigued and confined to bed than those with other forms of thyroid disease.

De Quervain’s is self-limiting, generally resolving within a few months, though chronic hypothyroidism (Hashimoto’s) is a common sequel.  

Lab testing in the acute stage shows elevated T4 and T3 with decreased TSH and elevated ESR (Erythrocyte Sedimentation Rate is a general measure of inflammation).

Differential Diagnosis

If you experience recent onset of extreme fatigue, malaise, heart palpitations, insomnia, emotional instability and tremors, you should ask your doctor to test you for hyperthyroidism. While waiting to see your doctor, start taking and recording your temperature and your pulse rate. A thermometer and pulse oximeter are both readily available at your local drug store. Measure yourself and write down the date and time of your measurements in a notebook or by other means.  Hyperthyroidism causes rapid heart rate and mild fever. Keeping a log of your temperature and pulse will help track the severity of your disease and the progress of your treatment. 

Unless you recently gave birth or are recovering from an infection, you likely have Grave’s disease. Your doctor will palpate your thyroid to check for swelling and also order blood tests to make a differential diagnosis. Most doctors will only order a TSH (Thyroid Stimulating Hormone) to determine whether or not you have hyperthyroidism. They do not typically order tests that quantify the autoimmune component. This is because the treatment for hyperthyroidism is to suppress thyroid hormone production with a bromide based drug or radioactive Iodine, not to try and modify the immune response.  A TSH below 0.3 is indicative of hyperthyroidism. I have listed other tests below that can be helpful in determining what is happening with the immune system and make a more informed differential diagnosis. I order these in addition to TSH, plus T4, T3 and reverse T3 (see prior article on hypothyroidism).

Test name Reference range Indication if high
Anti microsomal antibodies < 35 Units/ml Auto immune thyroiditis
Anti-thyroglobulin antibodies > 2 IU/ml Thyroid cancer or Hashimoto’s
Thyroid peroxidase antibody > 2 IU/ml Hashimoto’s or Grave’s
TSH receptor antibody <10% Grave’s

If you have hyperthyroid signs and symptoms following an acute infection, you would expect the diagnosis to be de Quervain’s hyperthyroidism.  If the onset followed the birth of a child, expect post-partum thyroiditis to be the diagnosis.  Neither de Quervain’s, nor post-partum thyroiditis are known for producing palpable swelling of the thyroid gland.  In lab testing, de Quervain’s patients can also expect an elevated ESR.  In both cases, elevated T3 and T4 with decreased TSH can be expected.

Hashimoto’s is more difficult to diagnose because it develops slowly.  It is an autoimmune thyroiditis but results in more destruction of tissue and therefore the clinical presentation is hypothyroidism.  The patient is cold, tired, has dry skin and thinning hair with a loss of the lateral third of the eyebrows (see article on hypothyroidism).  In her or his case, the thyroid gland is likely to be palpably enlarged and nodular.  Lab tests include elevated anti-microsomal and antithyroglobulin antibodies with decreased peroxidase antibodies.  Because of the possibility of thyroid cancer, I always refer out to her or his primary care physician or a specialist for evaluation in patient’s with thyroid nodules.

Etiology

So how does a patient get autoimmune thyroiditis?  The usual risk factors are genetics, prolonged high stress, female gender, environmental toxins, infections and low Selenium.  Let’s take these one at a time.

Genetics

There is a genetic predisposition to Grave’s disease that can be determined through HLA testing (The association is between HLA B8 and DW3 in Caucasians and DW35 in persons of Japanese descent), however it appears to be triggered by infection, stress and/or environmental toxins. Hashimoto’s also has a genetic pre-disposition.  In Caucasians, the HLA-B8, DR3 haplotype is associated with atrophic autoimmune thyroiditis.  HLA-DR5 is associated with goitrous autoimmune thyroiditis.  There is a high prevalence of autoimmune thyroiditis in Down’s syndrome, Turner’s syndrome and familial Alzheimer’s  further suggesting a genetic susceptibility.

High stress/ Low adrenal function

Stress provokes an increase in metabolic rate so that the person has the energy to deal with the crisis.  To raise metabolism, our bodies produce thyroid hormone, which sensitizes cells to adrenal medullary hormones, epinephrine and norepinephrine.  These are the hormones that increase metabolic rate.  The adrenal cortex produces hormones that balance water, salt, blood sugar, reduce inflammation, etc.  They are cooling, nourishing hormones.  High stress and insufficient adrenal cortical hormones to help the body cope with that stress may allow the development of autoimmune thyroiditis. 

Female Gender

Women are over three times more likely to have autoimmune thyroid disease than men.  The stress of childbirth is also a cause of autoimmune thyroiditis.  Post-partum thyroiditis is an example of the effect of physical stress leading to this condition and is of course, a form of the disease that is limited to women.  

Environmental toxins

The common lab tests for Grave’s and Hashimoto’s disease are antiperoxidase antibodies and anti thyroglobulin antibodies.  Several studies have demonstrated an association between exposure to PCB’s (polychlorinated biphenyls), dioxins, BPA (bisphenol A), perchlorate, DDE, hexachloroenzene and other toxins with elevated levels of these antibodies. 

How big a problem is this?  According to the National Health and Nutrition Examination Survey III, 13% of the total U.S. population is positive for both of these antibodies.  Thirteen percent is over thirty-nine million people!  That’s thirty-nine million Americans, whose immune systems are gunning for their thyroids.  Not all of those people have overt thyroid disease but individuals with both antibodies were 23 times more likely to be clinically hypothyroid and 12 times more likely to have sub-clinical hypothyroidism.  Individuals with both antibodies and a TSH over 2.5 were forty times more likely than the general population to have clinical hypothyroidism.  Remember, a TSH of 2.5 is ideal. In other words, your immune system could be attacking your thyroid and your lab test for thyroid disease could still be normal.

Infections

The last straw (in a patient already burdened with stress and toxins) can be an acute infection.  This would be diagnosed as de Quervain’s hypothyroidism but as you can imagine, the stresses that lead to de Quervain’s are likely to have been present for some time. 

Low Selenium

A little known nutritional factor in autoimmune thyroid disease is Selenium deficiency.  Selenium is a trace mineral.  To understand why Selenium is important, you must first understand that the thyroid gland converts Iodide to Iodine and then attaches Iodine to Tyrosine to make the hormone thyroxine (T4) using hydrogen peroxide, a potent oxidant at both steps.  If you have ever put hydrogen peroxide on a cut, you know that it fizzes as it tears cells apart.  That’s what makes it an effective antibacterial.  To protect your healthy cells, the thyroid produces glutathione peroxidase, a Selenium dependent enzyme.  Glutathione peroxidase neutralizes hydrogen peroxide.  If you are deficient in Selenium, you cannot produce adequate glutathione peroxidase and the resulting excess hydrogen peroxide damages your cells.  In response to this damage, the immune system begins to regard the thyroid gland as a source of trouble and starts coding antibodies against the thyroid.  If you recall, one of those enzymes discussed above is antithyroiperoxidase or anti-TPO.  Is this making sense?

Selenium is so important that the thyroid gland has higher concentrations of Selenium than the liver.  Furthermore, deficiency of Selenium is associated with cancer of the thyroid.  Exposure to chemicals that disrupt the thyroid’s ability to make glutathione peroxidase such as DDT, increase the risk of thyroid cancer.  Prolonged stimulation by high levels of TSH increases cellular differentiation in the thyroid and increases the risk of neoplasia.  High TSH is often a response to low levels of Iodine (see below) and high levels of exposure to toxic chemicals.  Add high TSH to prolonged exposure to thyroid disruptor chemicals and you have a recipe for thyroid cancer.  The rate of thyroid cancer in the United States has more than doubled over the last 30 years.

Clinically, if a hyperthyroid patient takes Iodine without first ensuring adequate levels of Selenium, symptoms are likely to worsen.  Of course, Selenium can be given as a nutritional supplement but the therapeutic range is very small.  The RDA is 400 mcg’s per day and toxicity can occur with as little as 1000 mcg’s per day.  Blood, urine or hair analysis can be performed to determine if the patient has adequate selenium.  The lab I use to test levels of minerals and heavy metals is Doctors Data in Chicago.  

A more traditional East Asian method of supplementing Selenium is to use Huang Chi or Radix Astragalus as this herb contains a concentration of Selenium.  This herb is used in many tonic formulas, notably Ginseng and Astragalus Formula or Bu Zhong Yi Chi Tang.  This is often the best formula for the adrenal deficient patient who is pre-clinical for a thyroid disorder or the patient with Hashimoto’s thyroiditis.  Furthermore, Astragalus Membranous is not only known to raise serum Selenium levels, it also boosts immunity to viral infection by raising levels cytokine and T cell immunity.  By helping to protect the body against infection, it reduces the risk of de Quervain’s thyroiditis.  

Acupuncture and Chinese Medicine

According to the oldest Chinese medicine text, “A superior physician prevents disease.  An inferior physician treats disease”.  Of course, patients don’t usually come in until they are sick but whenever possible, in our office we focus on prevention.  In the pre-clinical stage, we often see patients who are anxious and run down.  They are not yet sick but their lifestyle is spreading their energy too thin.  To these patients, I sometimes relay an old Chinese saying, “If we don’t change direction, we will end up where we are headed”.  Using acupuncture and tonic herbs to relax and strengthen the patient may get their attention so they will be more open to following our advice.  A program of Tai Chi, Chi Gung, yoga or other relaxation techniques and breathing exercises can really help.  We counsel patients to set priorities, accept limits and let go of trying to be and do everything.

Acupuncture can modulate immune response and reduce inflammation in the acute stage of the disease.  In the post-acute hypothyroid stage (Hashimoto’s), acupuncture and tonic herbs can help to modify the immune response and raise metabolism.  Nutritional therapy is also very helpful.

L-Carnitine

During the acute stage of hyperthyroidism, the amino acid L-Carnitine can be used to prevent or minimize the symptoms and physiologic changes associated with elevated levels of T3 and T4.  The dosage required is 2 – 4 grams per day of oral L-Carnitine, given in a divided dose.   

L – Carnitine is a normal amino acid found most abundantly in meats.  The supplemental form is made by bacteria and is easily absorbed and utilized as it is in a free, single amino acid form as opposed to complexes with other amino acids as it is normally found in food.  The mechanism of action for L-Carnitine is that it blocks the uptake of T3 and T4 at the cell nucleus.  Thyroid hormone works by causing transcription of DNA in the cell nucleus that increases receptor sites for catacholamines in the cell membrane.  Without access to the nucleus, T3 and T4 cannot raise metabolism and cause hyperthyroidism.  

Iodine

Since T3 and T4 are made from Iodine, it would be natural to assume that taking Iodine would worsen hyperthyroidism because the body would be able to make more of the hormones.  This is true in the acute stage, particularly if there is a lack of Selenium.  But in the post-acute stage, taking Iodine can actually decrease the levels of antithyroglobulin antibodies and antiperoxidase antibodies found in Hashimoto’s disease.

What to do?

First of all, make an appointment with your doctor. In this office, we are not medical doctors, let alone endocrinologists. We do not prescribe drugs. We offer nutritional support, lifestyle recommendations and supportive care. While it is true that we have helped many patients with thyroid disorders improve their health and it is also true that we provide treatment for aspects of thyroid disease often ignored by medical doctors, there are some cautions to bear in mind. First of all, if your heart rate is above 100 at rest, you may need to take medications to reduce the amount of thyroid hormone produced and reduce its effects on your heart. Secondly, if you have nodules on your thyroid gland, those should be checked for cancer.

The next thing to do is start measure and recording your resting pulse rate and temperature. Make a chart with these headings: Date, Time, Pulse Rate, Temperature, Symptoms. You are the only person who is with you all the time. We doctors are not. By taking an active role in your health, you will notice what helps you and what hurts you. There may be foods that make you better or worse, sleep patterns, stressors, etc. Be an expert in what makes you feel good.

Last, strive to maintain a relaxed, happy mood. Fear and anxiety hurt you. Anger hurts you. These emotional states trigger a flood of hormones that arouse your immune system and cause more destruction. A friend once said, “You can’t afford the luxury of a negative thought.” Sure your spouse may deserve a good tongue lashing but the person who will suffer is you. I have one patient who put her Grave’s disease in remission largely by walking away from everything stressful in life. She won’t even read the news or watch a suspenseful movie. It’s not worth it to her. She is happy gardening, cooking and reading, so that’s where she puts her focus. Does life still bring crisis that must be managed? Of course. We all have major life events that require us to get into high gear. We just don’t have to be in that heightened state all the time. It may be a habit. We may have built our roles and personalities around unsustainable demands.  Many of us are attracted to high stress activities, whether it is completing a big project at work, skiing down a steep hill or engaging in emotional dramas. Adrenaline makes us feel more alive. It may not seem possible to disengage from these high stress activities – that we “have to” do (fill in the blank), but many of them are optional. If you can turn a diagnosis of hyperthyroidism into a change towards a happier, less stressful life, the suffering will at least have meaning and possibly be worthwhile. Let the crisis be an opportunity to create a healthier, happier life.

Wishing you the best of health,

David Wells, D.C., L.Ac., MS (Nutrition).

 

 

 

References:

 Neufeld M, Blizzard RM.  Polyglandular autoimmune diseases. In: Pinchera A, Doniach D, Fenzi GF, eds. Symposium on Autoimmune Aspects of Endocrine Disorders. New York, NY: Academic Press’ 1980:357-365.

 Dayan CM, Daniels GH. Chronic autoimmune thyroiditis. N Engl J Med 1996;335:99-107.

 Progress in Autoimmune Diseases Research, NIH Autoimmune Diseases Coordinating Committee, Report to Congress, March, 2005

 Progress in Autoimmune Diseases Research, NIH Autoimmune Diseases Coordinating Committee, Report to Congress, March, 2005

 SEER Fact Sheet Thyroid, NIH 2009, www.cancer.gov

 Othman S, Phillips DIW, Parkes AB, et al. A long-term follow-up of postpartum thyroiditis. Clin Endocrinol (Oxf) 1990;32:559-564. [Medline]

 Pratt D, Novotny M, Kaberlein G, Dudkiewicz A, Gleicher N. Antithyroid antibodies and the association with non-organ specific antibodies in recurrent pregnancy loss. Am J Obstet Gynecol 1993;168:837-841. [Medline]

 Merck Manual, 2010

 Neufeld M, MacLaren N, Blizzard, R.  Autoimmune Polyglandular Syndromes. Pediatric Annals 9:4. 1980. p 48.

 Dayan CM, Daniels GH. Chronic autoimmune thyroiditis. N Engl J Med 1996;335:99-107.

 Shnell LM, Gallo MV, Ravenscroft J, DeCaprio AP. Persistent organic pollutants and anti-thyroid peroxidase levels in Akwesane Mohawk youg adults. Environ Res 2009;109:86092.

 Tsuji H, Sato K, Shimono J, et al. Thyroid function in patients with Yusho; 28year follow-up study. Fukuoka Igaku Zasshi 1997;88:231-235. 

 Spencer CA, Hollowells JG, Kazaosyan M, Braverman I.E. National Health and Nutrition Examination Survey III thyroid-stimulating hormone (TSH)-thyroperoxidase antibody relationships demonstrate that TSH upper reference limits may be skewed by occult thyroid dysfunction. J Clin Endocrinol Metab 2007;92:4236-4240.

 Surks MI, Hollowell JG. Age-specific distribution of serum thyrotropin and antithyroid antibodies in the U.S. population: implications for the prevalence of subclinical hypothyroidism. J Clin Endocrinol Metab 2007:92:4575-4582.

 Aaseth, J., Frey, H., Glaattre, E., Norheim, G., Ringstad, J. and Thomassen, Y. Selenium Concentrations in the human thyroid gland. Biol. Trace Element Res. 1990:24, 147-152

 Santini F, Vitti P, Ceccarini G, Mammoli C, Rosellini V, Pelosini C, Marsili A, Tonacchera M, Agretti P, Santoni T, Chiovato L, Pinchera A. Endocrinol Invest. 2003 Oct;26(10):950-5.

 Hard GC. Environ Health Perspect. 1998 Aug;106(8):427-36.

 Chen AY, Jemel A, Ward EM. Increasing incidence of differentiated thyroid cancer in the United States, 1988-2005. Cancer. 2009;18:784-791.

 Dong Xiang-yu, Ni Qian, Shen Yang. Effect of Astragalus Injection on levels of blood selenium and immunity function in children with viral myocarditis Chinese Journal of Integrative Medicine. Vol 10, No 1, 2004:29-32.

 Benvenga S, Amato A, Calvani M, et al. Effects of carnitine on thyroid hormone action. Ann N Y Acad Sci. 2004 Nov;1033:158-67.

 Benvenga S, Lakshmanan M, Trimarchi F. Carnitine is a naturally occurring inhibitor of thyroid hormone nuclear uptake. Thyroid. 2000 Dec;10(12):1043-50.

 Benvenga S, Ruggeri RM, Russo A, et al. Usefulness of L-carnitine, a naturally occurring peripheral antagonist of thyroid hormone action, in iatrogenic hyperthyroidism: a randomized, double-blind, placebo-controlled clinical trial. J Clin Endocrinol Metab. 2001 Aug;86(8):3579-94.

 Rink T, Schroth HJ, Holle LH, et al. Effect of iodine and thyroid hormones in the induction and therapy of Hashimoto’s thyroiditis. Nuklearmedizin. 1999;38(5):144-9.

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

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