Dietary calcium doesn’t make your bones stronger after all

Although it is current practice to prescribe vitamin D and calcium together, particularly in post menopausal women, a six year study shows that the added calcium has no value.

The women were all over the age of 65 and had osteopenia. This is the stage before osteoporosis. 1,994 women were randomised to take zolendronic acid or placebo.  Bone mineral density was measured at the spin, total hip, femoral neck and total body three times at intervals.

The baseline BMD was unrelated to dietary calcium after controlling for age, height, weight, physical activity, alcohol intake, smoking and past HRT use when a cross section of women were studied.

Loss of BMD over the next six years was not related to the amount of dietary calcium ingested.

Bristow SM et al. Dietary Calcium intake and bone loss over six years in osteopenic post menopausal women. J Clin Endocrinol Metab. 2019 Mar 21.

My comment: Maybe time to ditch the calcium?

And while we are on the subject of bones, I’m pleased to say that another study has shown that high dose vitamin D supplementation does NOT increase kidney stone risk.

Over just over 3 years of taking 100,000 iu of vitamin D3 each month did not increase excess calcium in the blood or the onset of kidney stones in adults aged between 50 and 84 years.

This dose is equivalent to 3300 iu vit D3 a day, similar to what many of us in the know take.

158 people took part in the randomised trial. The number of people developing kidney stones was similar in each group and no one in the intervention group developed hypercalcaemia.  The groups self reported stones. No ultrasound was done which the authors say could have been more accurate.

Malihi Z et al. Monthly high dose vitamin D supplementation does not increase kidney stone risk or serum calcium: results from a randomised controlled trial. Am J Clin. Nutr. 2019 Apr 21

 

Matthew’s Friends: a lifeline for epileptic patients

The charity Matthew’s Friends was set up by Emma Williams whose son Matthew got a great improvement in his epilepsy which did not respond to drugs but did respond to a ketogenic diet.

The charity aims to promote the ketogenic dietary option as an adjunct or alterative to drugs in children or adults whose epilepsy control is sub optimal. The hassle of following the diet often becomes much more preferable to facing a daily struggle with unpredictable and dangerous fits.

The website, Matthew’s Friends#KetoKitchen You Tube channel gives free ketogenic recipes, demonstrations and tutorials, which can be a great help to those embarking on ketogenic or low carb diets, including many diabetics. 

Professor Helen Cross from Great Ormond Street Hospital writes: Epilepsy affects 1% of all children, and in 25% of cases  there are continued fits despite considerable effort with medication. This can affect physical and mental ability, learning and behaviour. This not only affects the child but their family. The ketogenic diet has been used for almost one hundred years to treat epilepsy. There are different versions of the diet. The long chain triglyceride diet, the more liberal medium chain triglyceride diet, the modified Atkins and Low Glycaemic index diet. The best diet for an individual will be developed with the help of qualified and trained ketogenic dieticians in conjunction with the family. Such help is essential. In 60% of people who are resistant to anti-epileptic drugs, they respond, at least  to some extent to a ketogenic diet.

A three month trial of the ketogenic diet is advised to see if there is a response or not.In many cases, the response is so marked that medication can be stopped entirely. Obviously, direct clinical supervision is mandatory.

Matthew’s Friends can advise parents or people who would like to improve their epilepsy and provide contacts and materials to get started on an appropriate ketogenic diet. They are always grateful for donations to further their work.

Chief Medical Officer Scotland: Vitamin D supplementation

From letter from Dr Catherine Calderwood Chief Medical Officer Scotland 
24 November 2017

New Recommendations on Vitamin D Supplementation

Vitamin D plays an important role in maintaining bone health throughout life. Vitamin D deficiency impairs the absorption of dietary calcium and phosphorous. This can lead to:
 Infants having muscle weakness and bone softening leading to rickets;
 Adults having muscle weakness and osteomalacia, which leads to bone pain and tenderness.
The most recent National Diet and Nutrition Survey shows that a proportion of the UK population has low vitamin D levels, which may put them at risk of the clinical consequences of vitamin D deficiency.
Last year, the Scientific Advisory Committee on Nutrition (SACN) made new recommendations on vitamin D and health.  The full report is available at:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/537616/SACNVitamin_D_and_Health_report.pdf

SACN considered all relevant evidence suggesting links between vitamin D and various health conditions and concluded that the risk of poor musculoskeletal health (e.g. rickets, osteomalacia) is increased with low vitamin D levels. SACN found insufficient evidence to draw firm conclusions on the impact of low vitamin D levels for non-musculoskeletal health outcomes.
The Scottish Government has now updated its advice on vitamin D in line with the new SACN recommendations as follows:

Everyone age 5 years and above should consider taking a daily supplement of 10μg of vitamin D, particularly during the winter months (October – March). Between late March/early April and September, the majority of people aged 5 years and above will probably obtain sufficient vitamin D from sunlight when they are outdoors, alongside foods that naturally contain or are fortified with vitamin D.
From October to March, everyone aged 5 and over will need to rely on dietary sources of vitamin D. Since vitamin D is found only in a small number of foods, it might be difficult to get enough from foods that naturally contain vitamin D and/or fortified foods alone.

Children aged 1 to 4 years of age should be given a daily supplement containing 10μg vitamin D. We recommend Healthy Start vitamin drops for all children in health.

A new-born baby’s vitamin D level depends on their mother’s levels near the birth and will be higher if the mother took a vitamin D supplement during pregnancy. Some mothers and babies have a higher risk of vitamin D deficiency, including those born to mothers who habitually wear clothes that cover most of their skin while outdooors and those from minority ethnic groups with dark skin such as those of African, African-Caribbean and South Asian origin.
However, as a precaution, we are now recommending that all babies from birth up to one year of age should be given a daily supplement of 8.5 to 10μg vitamin D. Babies who are formula fed do not require a vitamin D supplement if they are having at least 500ml per day, as infant formula already has added vitamin D.
We recommend Healthy Start vitamin drops for infants. Neonatologists and paediatricians may recommend alternatives for premature infants, children with clinical conditions or clinical presentations of vitamin D deficiency.
Advice for parents on vitamin D supplementation for breastfed babies must be carefully considered as there is a risk that infant formula could be viewed as superior to breastmilk. Breastfeeding is the normal way to feed infants. It has an important and lasting impact on the public health of the population and it is vital that we protect and support breastfeeding. It is recommended that you emphasise that the potential problem is related to a lack of sunlight in the UK, and that it affects the whole 
population, not just breastfed babies.
It is recommended that those at greatest risk of vitamin D deficiency take a daily supplement all year round. These groups include:
pregnant and breastfeeding mothers
 children under 5 years of age
 people who are not exposed to much sunlight, such as frail or housebound individuals, or those that cover their skin for cultural reasons; and
 people from minority ethnic groups with dark skin such as those of African, African-Caribbean and South Asian origin, because they require more sun exposure to make as much vitamin D.
General information leaflets on vitamin D for both the public and healthcare professionals have been updated to reflect these new recommendations and are available online at: http://www.gov.scot/Topics/Health/Healthy-Living/Food-Health/vitaminD
New guidance has been developed for parents and healthcare professionals to support parents to follow this new recommendation. This includes advice on how to administer vitamin D drops to young babies. It is available at:
http://www.gov.scot/Topics/Health/Healthy-Living/Food-Health/vitaminD
From April 2017, Healthy Start vitamins for women (which provide Vitamin D, folic acid and Vitamin C) are provided free of charge to all pregnant women in Scotland for the duration of their pregnancy, regardless of their entitlement to the Healthy Start scheme.
Breastfeeding women and children up to age 4 who are eligible for Healthy Start can also get free supplements containing vitamin D. Further information on the Healthy Start scheme can be found at http://www.healthystart.nhs.uk
Healthy Start vitamin drops for babies and children currently contain 7.5μg per 5 drops of vitamin D, as well as vitamin A and vitamin C. The new recommended dose for vitamin D is 8.5-10μg and vitamins containing the new recommended dose will be available from October 2018. In the meantime, parents should be advised to continue to give the current dosage of 5 drops per day.
In Scotland, NHS Boards are responsible for supplying Healthy Start vitamin supplements universally to pregnant women and to breastfeeding women and children who are eligible for the Healthy Start scheme. NHS Boards are also able to sell Healthy Start vitamins to families who are not eligible for Healthy Start. Some Health Boards have chosen to provide additional free vitamins for infants.
We are not currently in a position to extend universal provision of vitamin supplements to the whole of the Scottish population or to additional at risk groups including the elderly, women in the pre-conception period, infants or young children.
Vitamin D supplements for adults and children are also available to buy from most major supermarkets, high street pharmacies and health food stores.

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Liraglutide can improve fatty liver damage as well as blood sugars

Adapted from Glucagon like peptide-1 receptor agonists for the management of obesity and non-alcoholic fatty liver disease: a novel therapeutic option. 

Gauri Dhir and Kenneth Cusi  Endocrinology/Metabolism Review Volume 66 Issue 1 2018

Obesity is a major risk factor for type two diabetes and a cluster of metabolic factors that lead to poor cardiovascular outcomes.  The amount of fat stored in the liver tissue closely mirrors insulin resistance and metabolic health.

Non alcoholic fatty liver disease (NAFLD) is now the commonest form of liver disease in the western world and can lead progressively to non alcoholic steatohepatitis (NASH), cirrhosis and hepatocellular carcinoma.

NAFLD is present in two thirds of obese people and promotes type two diabetes.  NASH is present in half of these. NAFLD is expected to become the most common cause of liver transplantation by 2020.

Pioglitazone and the newer drugs such as Liraglutide (Victoza) can be used, as well as various dietary therapies.

If a weight loss of 10% can be achieved, there is a significant improvement in the inflammatory process that results in cell death and fibrosis in NASH. But weight loss is difficult to achieve and maintain.  Pioglitazone can improve  NASH in two thirds of non- diabetic patients and by around half in those with diabetes or pre-diabetes.  Vitamin E has also been shown to have some success in non diabetic patients.

Liraglutide and drugs of the same class affect insulin secretion in response to meals, beta cell proliferation, inhibition of glucagon secretion, delayed gastric emptying, and making you feel fuller with less to eat.

These effects result in worthwhile clinical outcomes in overweight or obese patients whether they have diabetes or not. Body weight is reduced by at least 5% in 30% of patients and by at least 10% in 30% of patients. Over three years this can result in complete remission of the diabetes or pre-diabetes in 30% of the patients. Cardiovascular outcomes are also improved.

Triglyceride accumulation in the liver cells is the mechanism that has been recently shown to cause insulin resistant adipose tissue.  After 48 weeks of high dose Liraglutide (1.8 mg a day), resolution of NASH was seen on biopsy samples in 39% of the treated group compared to 9% in the placebo group.

The main side effects are nausea and diarrhea.  There could possibly be more gallstone development but no increase in pancreatitis.

Scottish Diabetes Survey 2016: are we winning or losing the diabetes struggle?

In Scotland 5.4% of the population is registered as having diabetes. 10.6% have type one and 88.3% have type two. 1.1% have other types such as Maturity Onset Diabetes in the Young.

In type ones 37.3% are overweight and a further 26% are obese. So 36.7% are of normal weight. In type twos 31.6% were overweight and 55.6% were obese. So only 12.8% were normal weight.

The annual HbA1c was done in over 90% of diabetics in both groups. 24.5% of type ones and 58.6% of type twos met the target of less than 58 mmol/mol which is equivalent to 7.5%.

Over 84.9% of both groups had their blood pressure measured that year and 45% of type ones and 32.7% of type twos met the target of less than 130 mmHg systolic.

Cholesterol levels were done in 86.4% of patients and this met the target of less than 5 mmol/l in 69.1% of type ones and 78.4% of type twos.

22.9% of type ones were current smokers compared to 17.2% of type twos.

Eye screening was undertaken in 85.4% of diabetics that year. 59.1% had had their feet checked and the score recorded.

When it comes to end stage disease in type ones, 3.5% had had a heart attack, 2.6% had had coronary revascularisation, 1.4% had end stage renal failure and 1.1% had had a major limb amputation.

In type twos, 9.7% had had a heart attack, 7.5% had had revascularisation, 0.6% had end stage renal failure and 0.7% had had a major amputation.

Overall 10.8 of the diabetic population use insulin pumps.

My comments: It can be seen from the data that screening is  doing very well. We have an average number of people with diabetes and the distribution between types one and two has not changed. Smoking is an issue in only about 20% of diabetics which probably compares favourably with social norms.

We have lost the battle of the bulge. Only 12.8% of type twos are of normal weight. Type ones are more like the “norm” for Scotland with just over a third being of normal weight.

Blood sugar control is very poor particularly in type ones with about three quarters of them with blood sugars over 7.5%. 

When it comes to complications, type twos are much more likely to get cardiac problems whereas type ones are more likely to get renal failure and amputations. 

 

When do you stop getting benefits from exercise?

From Danielle Baron’s article in International Medical News 10 August 18

As with many different health interventions, there is a sweet spot between doing enough of it and doing too much of it. Too little, and it is not effective. Too much and you could cause unexpected negative repercussions.  The subject of exercise has been investigated regarding its effect on mental health.

Over 1.2 million USA citizens were asked about their exercise habits and their mental wellbeing between 2011 and 2015 by researchers at the Centers for Disease Control and Prevention.

All exercise types improved mental health but popular team sports were particularly effective in boosting mental health. The optimal duration of exercise was between 30 and 60 minutes a session, three to five times a week.

Sessions of longer than 90 minutes or done more than 23 times a month however, were related to WORSE mental health.

The authors conclude that blanket advice on exercise could be improved by being more specific about the types, durations and frequencies that were more likely to improve mental health and that further studies could be helpful.

Chekroud SR et al. Association between physical exercise and mental health in 1.2 million individuals in the USA between 2011 and 2015: a cross sectional study. Lancet Psychiatry. Published online 8 August 2018. doi: 10.1016/S2215-0366(18)30227-X

My comments: Oh dear! Well, I’ve got the duration right at 40 minutes but I hate team sports (because I’m useless at hand to eye or foot coordination) and I aim to exercise every day, which these researchers considered “excessive”.  Maybe the team sports were more beneficial because of the socialisation aspect as well as the physical aspect. Maybe less than 23 times a month made it something to look forward to and a dopamine hit , “I’ve achieved that” rather than a black mark ” I failed to do my exercise session”   as I tend to think about it. I can see the downsides of exercise addiction reflected in this piece of research. 

High dose Vitamin D improves cardiovascular health markers

Adapted from UK Medical News 17 July 2018

Several different health measures, all which improve your cardiovascular outcomes, have been found to result from high dose vitamin D supplementation. You are likely to need to take at least 4,000 iu a day though, depending on how much extra sunshine you are exposed to regularly.

A meta-analysis of 81 randomised controlled trials looked at almost one thousand patients randomised to taking supplements or to a control group who did not. The active and control groups were both roughly 5,000 each.  The durations of the trials varied but averaged out at ten months. The doses ranged from 400 iu a day to 12,000 iu a day. The average taken was 3,000 iu a day.

The outcomes were related to the blood level of vitamin D achieved. Levels had to be over 86 nmol/L to get benefits. You need to take over 4,000 iu a day to get vitamin D concentrations of 100 nmol/L or more.  My comment:This does mean that the minimum levels advised by the Scottish Chief Medical Officer last year are way too low to see the benefits discussed here.

So what extra benefits do you see?

lower systolic and diastolic blood pressure.

lower high sensitivity C reactive protein.

lower serum parathyroid hormone.

lower triglycerides.

lower total cholesterol.

lower low density lipoprotein.

high density lipoprotein increased.

All benefits were numerically small but did reach statistical significance. Cardiovascular outcomes were not measured directly, only blood markers and blood pressure.

Mirhosseini N et al. Vitamin D Supplementation. Serum 25(OH)D Concentrations and cardiovascular disease risk factors: A systematic review and meta-analysis. Front Cardiovasc Med. 2018 July 12.