Report From the LI Conference, part 24

A lot of good stuff in the next presentation, so let's jump right in.

Treatment Recommendations in Children
Catherine M. Gordon, M.D., M.Sc.
Director
Children's Hospital Bone Health Program
Adolescent/Young Adult Medicine and Endocrinology
Children's Hospital Boston
Associate Professor of Pediatrics
Harvard Medical School

A big question that I haven't seen answered before is whether avoiding dairy - and not making the effort to replace the calcium that would be found in a dairy heavy diet - really makes a difference to health.

There are a few studies which say that not having dairy hurts your bones. And generally speaking, we can say that people who know they are lactose intolerant (LI) have less dairy - if any at all - than people who don't consider themselves to be LI. Vertebral fractures are higher in people with LI. Bone mineral density is lower, and the more severe the symptoms reported the lower the density became. This started to be true even in a population of girls aged from 10 to 13. If children aren't having dairy, they are highly unlikely to do so later in life.

How to get more dairy into your diet if you have LI? Here are several suggestions.

1. Consume small amounts of lactose-containing foods.

2. Chronic/repeated intake of lactose-containing foods allows colonic bacteria to adapt and more efficiently metabolize lactose.

3. Co-ingest lactose-containing foods with a meal.

4. Consider the form of the lactose-containing food. Hard cheeses, chocolate, higher fat milks, and ice cream are well tolerated.

5. Eat live culture yogurt.

6. Utilize commercially available lactose digestive aids.

7. Modify behaviors and perceptions from past experiences to learn that dairy/lactose-containing foods can be easily incorporated into the diet.

8. Consider the consumption of calcium-fortified foods.

The idea behind having more dairy is getting the calcium it provides. If you don't want dairy in your diet, calcium supplements are a useful source. Just be sure not to take more than 500 mg of calcium in any individual dose. Some people get constipation from calcium supplements. Before quitting them, try increasing the amount of fiber and water in your diet to see if that counteracts the constipation.

Children can take any of several varieties of supplements, including the common calcium carbonate (which is more likely to be found in chewable form), calcium citrate, and calcium glubionate.

Report from the LI Conference, part 16

You want embarrassing?

Say you have a major federal agency, one that has responsibilities for a major, crucial, fraction of the nation's wellbeing. Call it, say, the National Institutes of Health. Make them responsible for the program of a major scientific get-together, say the state-of-the-science conference on Lactose Intolerance. And give that agency the very simple, basic responsibility of making the individual segments of that conference program accessible on the Internet, say, by posting links to each presentation and abstract. You do that, as everyone who has any knowledge of the Internet knows, by taking the URL and adding a # plus the name of an internal link.

So the URL for a link to, say, Evidence-based Practice Center Presentation II:
The Bone Health Outcomes of Dairy-Exclusion Diets by Timothy J. Wilt would read something like this:

http:// consensus.nih.gov/2010/lactoseabstracts.htm #Wilt

Simple enough.

Unless, that is, said Timothy J. Wilt, M.D., M.P.H. is the author of two different presentations. In which case, a URL that reads:

http:// consensus.nih.gov/2010/lactoseabstracts.htm #Wilt

takes you to the first of the two. And never the second. So I can't give you a direct link to the abstract of Evidence-based Practice Center Presentation II:
The Bone Health Outcomes of Dairy-Exclusion Diets because the boneheads at the NIH didn't think to make the link read #Wilt2.

Programming, even HTML-markup, is all details. Mistakes and typos are all too easy to make. But somebody has to click on all the links to make sure they work!

Anyway, for all the info about Dr. Wilt and his co-authors, see the entry I posted about part I of their multi-part presentation.

This particular presentation looked again at actual consumption of nutrients among those who had dairy and those who didn't. What happens with those who don't eat or drink dairy? They don't get enough calcium.

Vegan children consumed only 47% of the RDA for calcium. Vegan women got even less, a mere 30%.

The numbers were extremely similar for LI children (45%) and LI women (37%). LI, lactose intolerance, is being defined here as anyone who claimed symptoms from dairy. Those who tested as having a lactase deficiency, technically a somewhat different group, had a somewhat but not terribly different pattern, 44% for children, 50% for women. (Why no results for men? Apparently none of the 52 studies they summarized looked specifically at males apart from other groups.)

Does this lack of calcium make any real different for bones? The evidence there was thoroughly mixed. Some studies found no differences at all, but many did show increases for bone problems of all sorts for people who avoided dairy.

Report from the LI Conference, part 14

For the next three posts, we'll be in Section 2 of NIH state-of-the-state presentations on Lactose Intolerance.

What are the health outcomes of dairy exclusion diets?

Consequences of Excluding Dairy, Milk Avoiders, Calcium Requirements in Children
Connie M. Weaver, Ph.D.
Distinct Professor and Head
College of Consumer and Family Sciences
Department of Foods and Nutrition
Purdue University

Although it is perfectly true that a totally adequate intake of nutrients can be achieved without consuming any dairy products, the reality is that Americans as a whole don't follow anything like that diet. They don't come close to getting sufficient nutrients even with dairy. The numbers are scary.

The role of milk products in meeting three nutrients for various age groups is illustrated in Table 1.

Most food guidance patterns recommend 3 cups of low-fat dairy products daily. The table contrasts the proportion of individuals meeting the dairy recommendations with those receiving less than one serving of dairy products as assessed from data from the 1999–2004 National Health and Nutrition Examination Survey (NHANES). The best and most economical source of the limiting nutrients is dairy. Supplements typically do not fill the gap of all these nutrients for those who do not consume recommended intakes of dairy products. Using NHANES 2001–2002 data, Gao et al. determined that it is impossible to meet calcium recommendations while meeting other nutrient recommendations with a dairy-free diet within the current U.S. dietary pattern. Using the 1999–2004 NHANES data, Nicklas et al. determined that < 3% of the U.S. population met potassium recommendations and 55% did not even meet their Estimated Average Requirements for magnesium.

Bone mass growth comes during adolescence, with 95% of adult peak occurring by age 16. Getting proper nutrients in childhood in critical. Dairy drinkers have a real advantage in driving those numbers up to and past the critical requirements. Here's a table of what the bone-related nutrient requirements are for those under 18.

Report from the LI Conference, part 12

Back from a short lunch we plunged directly into more presentations.

Aging: Lactose Intolerance and Calcium Absorption in the Elderly
Richard J. Wood, Ph.D.
Associate Professor
Department of Nutrition
School of Public Health & Health Sciences
University of Massachusetts

We're a nation of just over 300,000,000 people. We're also an aging nation. People are living longer than ever before, and the demographic bulge caused by the vastly increased birthrates that represent the baby boomer generation is moving to the older segment of the population. The first boomers are turning 64 this year. By the year 2030 there will be an estimated increase of 33 million people in the 65 and over age bracket, making a total of 25% of Americans. You can't blame the boomers entirely. The oldest will be only 84 that year but a full 5% of the population will be 85 or over then.

What happens to humans as they become older, an older population than ever before? Specifically, what do we know about the elderly and LI? As will be a woefully recurring theme, the answer is "next to nothing."

Although many studies have characterized the prevalence of lactose maldigestion and symptoms of lactose intolerance in various adult populations, there is surprisingly little information concerning this condition in the elderly, especially in the very old (>80 years). What little evidence is available indicates that the prevalence of lactose maldigestion may increase with age in adults, but that symptoms of lactose intolerance do not increase with age.

Little evidence means little evidence. Apparently fewer than a hundred elderly in total have ever been investigated in LI studies.

And those meager results are big time compared to the number of elderly patients tested to see whether lactose malabsorption affects calcium absorption. We just don't know. The possible good news is that tests on younger patients don't show any difference. Keep on having calcium in whatever form you like.

Milk Promotes Itself to Teens

Most Americans fail to get enough calcium in their diets, teens especially. As Dr. Nancy Krebs reported at the NIH LI Conference, most Americans get the vast majority of their dietary calcium from dairy products.

Put those facts together and you have an opportunity for milk to promote itself to teens. Not surprisingly, the Milk Processor Education Program (MilkPEP), the "Got Milk?" people, jumped heavily onto target market.

Successful Promotions magazine (there's magazine for everything) ran an article on MilkPEP's Get Fit by Finals campaign. The article Got Fitness? by Jean Erickson is available in Flash Paper format, the new worst way to read text on a computer screen. (Yes, it keeps viewers from copying text by highlighting and pasting, but who would want to copy text that they can't read?)

The Internet-heavy campaign features NBA All-Star Chris Paul of the New Orleans Hornets (give them back the Jazz name already) and WNBA All-Star Diana Taurasi. "Activation kits" were also sent to 40,000 schools.



It all seems to work.

Web traffic increased by 17% over previous teen fitness programs, and repeat visits to the site rose to an all-time record.

No hint in the article of how the program handled lactose intolerant, milk allergic, or vegan students, though.

Report from the LI Conference, part 4

Up next was another talk on the basics.

Nutritive Value of Milk and Alternative Sources
Nancy F. Krebs, M.D., M.S.
Professor of Pediatrics and Head of Section of Nutrition
Department of Pediatrics
Health Sciences Center
University of Colorado at Denver

We hear all the time from dairy advocates that dairy needs to be in the food pyramid and be recommended as a major food group because people just won't, at least don't, get their calcium from other sources, even though it's technically possible to.

I knew that, but the the numbers still managed to startle me. "Dairy products provide approximately 70% of calcium in the U.S. food supply." Vegetables are next, at a tiny 8% of the total. Replacing 70% of a critical nutrient is an almost impossible task in less than a generation. Maybe more. That 70% figure has gone down some but it's taken 45 years to do so, and that's with the growth in calcium-fortified foods.

If you do want to avoid milk, the calcium in calcium-fortified orange juice is well absorbed. So is the calcium in calcium-processed tofu and vegetables like kale. The calcium in spinach is not well absorbed, because it contains oxalates that interfere. Fortunately, oxalates are not a common problem in green leafy vegetables, and the ones that do have a high oxalic acid content include chard and beet greens, not huge contributors to the diet.

But if we tried we could just swap out these alternative sources for dairy, right? Sorry, we just don't know. No good studies of whether the functional outcomes of alternative calcium sources are equivalent to dairy have been done.

No Increased Risk of Kidney Stones from Extra Calcium

I always advise people who avoid dairy products to think about calcium supplements. Sure, the militant vegans are very loud and insistent that you can get a full allowance of calcium from non-dairy sources and that's technically true. The reality is that very few people eat that diet. Check out this government listing of nondairy calcium sources at Appendix B-4. It's neither large nor varied.

Therefore a calcium pill with added vitamin D to help absorption is normally a must for the average person. The type of calcium doesn't matter, unless you have difficulties manufacturing stomach acid. Some of the elderly and people on certain medication have this problem. For them the standard calcium carbonate is not the right option. Try calcium citrate instead.

One more problem. Americans are not a people who aim for "just right". When they don't under-do they overdo. Some people will have calcium from their food (some dairy as well as nondairy) plus calcium supplements. And that raises a risk of a calcium overconsumption.

Remember, the risk is being raised only from essentially zero to a tiny bit more than zero. The kidneys will strain out any slight excess of calcium and excrete it in the urine. This raises yet another issue. Kidney stones. Kidney stones typically are calcium precipitated out in the form of calcium oxalate or calcium phosphate.

Nobody wants the pain of passing a kidney stone. So do calcium supplements increase your risk of kidney stones?

Linda G. Fugate wondered about this on Enpowher.com.

The answer from the medical literature surprised me. In a study of men under the age of 60, the risk of kidney stones decreased with increasing calcium in the diet. This is backwards from what we would expect, and the authors of the paper have no explanation. For men over age 60, the amount of calcium in the diet had no effect on formation of kidney stones. I have not yet found comparable data for women. The main risk for kidney stones in women appears to be weight. See http://www.empowher.com/news/herarticle/2009/08/10/women-weight-and-kidn....

Researchers at the University of California report that potassium and bicarbonate ions tend to keep calcium in the bones, while sodium and chloride ions tend to increase calcium in the urine and promote the formation of kidney stones. Bicarbonate ions are formed from the metabolism of organic compounds, mainly citrate, found in fruits and vegetables. Potassium is also abundant in fruits and vegetables (but not grains).

According to these researchers, both potassium and bicarbonate have a positive effect on the kidney's ability to regulate calcium excretion. Bicarbonate also prevents calcium loss from the bones by balancing the pH (a measure of acidity or alkalinity) of the blood and tissue fluids. Too much sodium, on the other hand, interferes with the kidney's regulation of calcium.

So I'm continuing the calcium supplements and eating plenty of vegetables.

Good news. Keep adding calcium to your diet. Try to avoid overconsumption, but don't worry too much if you can't keep your dosages straight. Bookmark this. That's probably the first and last time I'll say anything so radical.

Non-Dairy Sources of Calcium

While I'm thinking about non-dairy sources of calcium, I should take you to the source of sources, the USDA's Food Sources of Selected Nutrients page.

There's a plenitude of good information on that page and you may want to bookmark it for the future.

In the meantime, I've copied the table on non-dairy sources of calcium.



Blogger tends to reduce photos even at their largest size, so let me emphasize what appears in the fine print. Not all foods that have good amounts of calcium are good sources of calcium because other chemicals in those foods block its absorption. That's what I wrote about yesterday. Even so, that list will give you a head start on foods you should be including in your diet if you are avoiding dairy completely.

Vinegar Helps Calcium Absorption

If you're going to drop dairy from your diet you need to make doubly sure you find ways to get the nutrients that dairy is famously has in abundance. Calcium is high on that list. Vegans are always quick to insist that you can get your calcium from green, leafy vegetables which are rich in calcium content. The latter high of that statement is true but the first half is more problematical.

Green, leafy vegetables contains chemicals called oxalates than bind the calcium in them, making the calcium unavailable for digestion. The calcium has low bioavailability, to put it another way.

About.com is a good source of information on oxalates.

Oxalates are naturally-occurring substances found in plants, animals, and in humans. In chemical terms, oxalates belong to a group of molecules called organic acids, and are routinely made by plants, animals, and humans. Our bodies always contain oxalates, and our cells routinely convert other substances into oxalates. For example, vitamin C is one of the substances that our cells routinely convert into oxalates. In addition to the oxalates that are made inside of our body, oxalates can arrive at our body from the outside, from certain foods that contain them.

Foods that contain oxalates

The following are some examples of the most common sources of oxalates, arranged by food group. It is important to note that the leaves of a plant almost always contain higher oxalate levels than the roots, stems, and stalks.

Vegetables
spinach, Swiss chard, beet greens, collards, okra, parsley, leeks and quinoa are among the most oxalate-dense vegetables
celery, green beans, rutabagas, and summer squash would be considered moderately dense in oxalates

So what is a dairy avoider to do?

Katie Alfieri, Rochester Wellness Examiner, blogged on Examiner.com that vinegar is the solution.

Dark, leafy greens are good sources of calcium, but some of these greens also contain compounds that inhibit calcium absorption. Adding a tablespoon of vinegar (either balsamic, apple cider or red wine) and 2 tablespoons of oil to your greens will allow you to absorb the calcium. This is especially beneficial for those who are lactose intolerant.

I always doublecheck information from Examiner.com, but in this case it's absolutely correct. The acetic acid in vinegar increases absorption of many important minerals. The oil is not strictly necessary but a vinaigrette is undoubtedly tastier for most folks. If taste is secondary you can even take a spoonful of vinegar with a glass of water before meals.

By the way, notice how many names of chemicals have littered this post. Beware anyone who talks about "chemicals" as some nasty, artificial creation to be avoided. Everything is a chemical and that means everything we eat is naturally no more than a huge mess o' chemicals. Without chemicals you would die instantly. Mostly because your body would simply disappear. Don't disparage chemicals. Celebrate them. It's our modern knowledge of chemicals that made the entire modern world of civilization possible. Every medication, natural, artificial, synthesized, or other is a chemical as well. Chemicals make you feel full, happy, and better. Understand them before you knock them.

Young Adults Not Getting Enough Calcium

I hate to keep harping on the need for calcium, but I can't ignore the fact that a new study seems to come out about every other week saying that some segment of the public isn't getting their RDA of calcium.

This week the culprits are young adults sayeth an accusatory article on Forbes.com. A University of Minnesota study of 1500 young-uns found that they started reducing their calcium intake in high school or soon after.

More than half of the males and more than two-thirds of the females consumed less than the daily recommended level of calcium at the end of each of those time periods, the researchers found.

The study findings are published in the July issue of the Journal of Nutrition Education and Behavior.

The study also took the time to check what else was correlated with lower calcium levels. Lactose intolerance was, not surprisingly. People who drink less milk tend not to get enough calcium from other sources either.

Also connected was "excessive television watching." TV watchers. Order more pizza. Double cheese. Heck, you're already fat.

One Third of Canadian Toddlers Are Vitamin D Deficient

I've posted that teens and adults are not getting sufficient vitamin D. But toddlers? Don't toddlers, you know, drink milk?

Apparently not enough, according to the TARGet Kids! (Toronto Area Research Group) study, a cross-sectional population-based dietary survey and clinical examination of Canadian toddlers. Medscape reporter Martha Kerr wrote that the study found 82% of the toddlers had vitamin D insufficiency and 32% were outright deficient.

You'd never guess what the risk factors were. OK, you'd probably guess if you've been awake at any time in the past decade. Snacking while tv watching and not enough milk drinking are the major culprits.

Low milk consumption "was independently associated with low vitamin D levels," Dr. [Jonathon Maguire, MD, a Fellow in the Division of Pediatric Medicine at the Hospital for Sick Children and the University of Toronto in Ontario] told Medscape Pediatrics. There was a 1 nmol/L increase in 25-OH vitamin D level for every ounce of milk consumed (P = .006).

High body mass index (BMI) was associated with vitamin D deficiency, with a 4.7 nmol/L decrease in 25-OH vitamin D level per BMI unit (P = .0009). "This may be associated with a higher fat content of the body," he commented. "Drinking more milk is not associated with a higher BMI, as some people think. In fact, the opposite is true."

TV viewing while snacking was also associated with vitamin D deficiency; the level is 9.6 nmol/L lower if the child watches TV while snacking (P = .022). "This might be related to more time spent indoors, a poorer nutritional intake, low levels of physical exercise ... or a combination of such factors, indicating an unhealthy lifestyle," Dr. Maguire commented.

Doctors are encouraged to screen children for these health risks, especially for drinking less than 12 ounces of a milk a day.

The study doesn't say, but for the sake of vegans I'd recommend a milk alternative that gives the equivalent calcium and vitamin to regular cow's milk.

Most People Need Calcium and Vitamin D Supplements

Here's a phrase that the quack supplement industry hates: "Your body doesn't absorb extra vitamins. All you get from taking vitamin supplements is expensive urine." There are many web pages devoted to "debunking" this as a myth. What none of them bother to mention was that the phrase came about to combat the supplement quacks who were pushing megadoses of vitamins as "cures" for all what ails ya. They were truly ripoffs.

After the megadose crazy faded, the antioxidant fad began. Large doses of Vitamins A and E were supposed to protect from heart disease and cancer. Except that they don't.

You do need some vitamins, of course. Getting the RDA of all the vitamins, minerals, and nutrients is essential. A good diet would provide those, if only more Americans had good diet habits. Since most don't an ordinary multi-vitamin pill couldn't hurt.

Are there any supplements you should take? Yes. As I've posted many times, you probably aren't getting enough calcium and vitamin D. Dr. Marc Siegel backs me up on this in an article from Fox News.

Vitamin D
A lack of vitamin D is associated with heart disease, muscle problems, a loss of mental acuity and fertility problems, Siegel said.

“Everybody should consider taking a vitamin D supplement,” Siegel said. “You need at least 400 international units per day. You should have your doctor check your levels (through a blood test).”

Siegel said proton pump inhibitors (medicines like Nexium or Protonix), which treat acid reflux symptoms, may block the body's absorption of vitamins B₁₂ and D, so anyone on those medicines should have their levels checked regularly. ...

Calcium
You should take 500 to 1,000 milligrams of calcium every day, especially if you are a post-menopausal female, Siegel said. Calcium is essential for keeping bones strong and preventing them from breaking.

Women should continue to get their calcium from outside sources, even if they are taking a supplement, Siegel said.

Strict vegans may be at risk for low levels of vitamin B₁₂ so that's one additional supplement worth taking by them.

You can find additional confirmation of the vitamin myth in Tara Parker-Pope's article, Vitamin Pills: A False Hope? in The New York Times.

Calcium-Fortified Lettuce?

Americans don't get enough of any nutrient, except possibly fat. Calcium is one that all studies agree that Americans of all ages, from teens on up, don't get enough of. So food chemists are putting calcium into all sorts of foods. Orange juice. Breakfast cereals. Soy milk. Bread. Water.

But lettuce?

Apparently. Food scientists Sunghun Park and Mark P. Elless think lettuce is the perfect vegetable for the purpose.

A new generation of calcium-biofortified lettuce is possible. Lettuce is an attractive choice for calcium biofortification. It is rich in vitamin K, and its daily consumption significantly reduces the risk of hip fractures in women compared to women who consumed lettuce at a lower rate. Therefore, the enhancement of calcium in lettuce could provide synergistic benefits to osteoporosis prevention. A large portion of women in the United States eat lettuce daily, suggesting calcium-biofortified lettuce for the prevention of osteoporosis would be consumed by a large target audience.

How in the world do you add calcium to lettuce?

One way to alter the calcium content in fruits and vegetables is to directly engineer these foods with calcium transporters. Simplistically, this strategy can be thought of as nutrient mining (biofortification)—where the nutrient is transported from soil into the edible portions of the plant. Specifically, a potential model for increasing the calcium content in edible foods would be to engineer plant endomembrane transporters to transport more calcium. The Ca2+/H+ antiporters, termed CAX (for cation exchangers), located on the vacuolar membrane, are important for calcium sequestration. This discovery led to an engineered version of a plant Ca2+/H+ antiporter, sCAX1, which could be used for calcium biofortification.

Clear?

Whatever this means, the authors say it's applicable to other vegetables as well. Skipping the supplements and getting more calcium directly from good foods might be a way out of the huge calcium hole we've dug ourselves into.

Everybody Needs More Vitamin D

Vitamin D is necessary for many reasons, not least because it helps the body absorb calcium better. I've been telling you You Need More Vitamin D with Your Calcium and that there are Vitamin D Deficiency Problems in Teens and Adults.

Now the American Academy of Pediatrics (AAP) has announced that it is doubling the amount of vitamin D it recommends for infants, children and adolescents.

The previous recommendation, issued in 2003, called for 200 IU per day beginning in the first two months of life.

The change in recommendation comes after reviewing new clinical trials on vitamin D and the historical precedence of safely giving 400 IU per day to the pediatric population. Clinical data show that 400 units of vitamin D a day will not only prevent rickets, but treat it. This bone-softening disease is preventable with adequate vitamin D, but dietary sources of vitamin D are limited, and it is difficult to determine a safe amount of sunlight exposure to synthesize vitamin D in a given individual. Rickets continues to be reported in the United States in infants and adolescents. The greatest risk for rickets is in exclusively breastfed infants who are not supplemented with 400 IU of vitamin D a day.

Adequate vitamin D throughout childhood may reduce the risk of osteoporosis. In adults, new evidence suggests that vitamin D plays a role in the immune system and may help prevent infections, autoimmune diseases, cancer and diabetes.

Adults may be higher recommendations as well, according to an article by Carol M. Bareuther on the Triton.

On the heels of the AAP’s announcement, the National Academy of Sciences’ Institute of Medicine (IOM) is set to review its recommendations for adults. Currently, adults up to age 50 should consume 200 IUs per day, adults aged between 51 and 70 should have an intake of 400 IUs, and adults aged 71 and over should consume 600 IUs.

I've noticed that major brands like Caltrate and the store brands that copy its lead have labels proclaiming "advanced levels of vitamin D" on its bottles of Calcium 600+D calcium supplement. That means 600 mg of calcium and 400 IU of vitamin D in each pill.

Be careful not to overdo the D. There are warnings associated with amounts of 2000 IU per day and over.

Add Vitamin D to Calcium to Reduce Osteoporosis Risk, Says FDA

I've told you bluntly that You Need More Vitamin D with Your Calcium. Why? According to The National Osteoporosis Foundation (NOF):

The relationship between calcium absorption and vitamin D is similar to that of a locked door and a key. Vitamin D is the key that unlocks the door and allows calcium to leave the intestine and enter the bloodstream. Vitamin D also works in the kidneys to help resorb calcium that otherwise would be excreted.

I've also given you ways on Adding Vitamin D to a Nondairy Diet.

Why do I remind you of all this? Because the Food and Drug Administration announced that it has amended its advice for reducing the risk of osteoporosis by recommending the use of vitamin D along with calcium.

The FDA site is hopeless to search, so I have to fall back on this press release. It was put out by the Coca-Cola Co., which gained permission to add vitamin D to the already calcium-fortified drinks it makes, especially orange juice put out under the Minute Maid label.

Anyway, here's the deal.

The amended labeling regulation explains that vitamin D is required for the normal absorption of calcium, and authorizes the health claim: "Adequate calcium and vitamin D throughout life, as part of a well-balanced diet, may reduce the risk of osteoporosis."

"Osteoporosis is a growing public health crisis, and all Americans, men and women alike, will benefit from knowing that vitamin D along with calcium can help delay or prevent the onset of this disease," said Robert P. Heaney MD, FACP, John A. Creighton University Professor and Professor of Medicine at Creighton University in Omaha, Nebraska. "Along with weight-bearing exercise, the most valuable intervention for maintaining bone health is an overall healthful diet that supplies adequate amounts of all nutrients such as vitamin D."

The US National Osteoporosis Foundation predicts that by 2010, about 12 million people over the age of 50 will have osteoporosis and another 40 million will have low bone mass. These numbers are expected to continue climbing. To help address this significant public health issue, the FDA developed this health claim for manufacturers to include on labels of appropriate foods and dietary supplements. The new labeling can help consumers identify products with adequate calcium and Vitamin D that can help to reduce their risk of osteoporosis.

Parents Can Now Ask Schools to Serve Soymilk

A press release from the Soyfoods Association of North America alerted parents to new rules from the U.S. Department of Agriculture (USDA).

The United States Department of Agriculture (USDA) announced parents or legal guardians may request, in writing, soymilk as an alternative to cow's milk for children receiving National School Lunch and Breakfast Program meals. This change caters to the growing diversity of participants in the School Nutrition Programs and allows children with lactose intolerance, dairy allergies or cultural diet restrictions to have an alternative source of calcium at school mealtime.

...

Recognizing the need for alternative calcium sources and low-calorie nutrient sources, USDA has included fortified soymilk in food supplement programs such as the Women, Infant, and Children Supplemental Food Packages and now the National School Lunch and Breakfast Program. The USDA Food Pyramid for Young Children also identifies soymilk as an alternative to dairy milk. The Institute of Medicine report, Nutrition Standards for Foods in Schools, recommends fortified soymilk be offered as a source of calcium for school children of all ages.

Milk-Alkali Syndrome

The medical advice column in the Hartford Courant is by Joe Graedon and Teresa Graedon and usually contains good-quality advice. So a scary-sounding problem in their February 22 column stopped me in my tracks:

Q: How much calcium is too much? I take 1,500 milligrams a day, and my doctor wants me to add another 500 milligrams for my thinning bones. I drink milk and wonder if I may be overdosing.

A: Too much calcium (2,000 milligrams a day) can lead to "milk-alkali syndrome." The extra supplement might make you vulnerable to this complication, which increases the risk of bone fractures and kidney stones.

In some ways, this answer is technically accurate. Mostly, though, it's extremely misleading, but I have to take it apart piece by piece to explain why.

First, milk-alkali syndrome.

Say that you have too much gastric acidity. You probably would want to neutralize the acid. Chemically, you neutralize an acid by adding an alkali to it. Acids and alkalis combine to produce water, which is neutral. Antacid pills - Tums, Rolaids, and the like - do this well enough that most people don't need anything more. What did people do before Tums? Back in 1915 a physician named B. W. Sippy invented the Sippy cup. No, he didn't, though that sure would make a fun fact. He invented a process that involved giving patients massive amounts of magnesium carbonate, sodium bicarbonate, and bismuth subcarbonate along with lots of milk.

Some of the more sensitive patients responded by having the acid levels in their blood go perilously low (and the alkali levels increase), called alkalosis. They developed kidney problems, renal insufficiency. And the calcium levels in the blood went too high, or hypercalcemia. The three conditions combined began to be called milk-alkali syndrome. It was never a fatal problem, but it sure wasn't something that was helpful.

The Sippy treatment got lost to medical history and by 1985 milk-alkali syndrome was seen in fewer than 1% of cases of hypercalcemia.

Then something odd happened. Doctors found milk-alkali syndrome in patients they were seeing for other problems, like renal disease or those taking calcium for osteoporosis. Suddenly as many as 12% of cases of people with these related problems had hypercalcemia.

The source of the overage in many cases was the easily available over the counter calcium that is everywhere in antacids and vitamin supplements and calcium fortified foods.

Remember that the RDA for calcium depends on age and sex, but the usual range for adults is from 1000 to 1300 mg per day. Suddenly taking 2000 mg a day, just an extra pill or two, would seem to put you in danger.

The full medical journal article on the subject available from eMedicine.com, Milk-Alkali Syndrome by R Hal Scofield, MD,Professor, Department of Medicine, Section of Endocrinology, Associate Member, University of Oklahoma Health Sciences Center, Arthritis and Immunology Program, Oklahoma Medical Research Foundation, admits that "How oral intake of more than 2 g/d [2000 mg per day] of elemental calcium with absorbable alkali results in hypercalcemia and alkalosis is not completely understood."

I can tell you right away that one thing not understood is that 2 grams (2000 mg) a day of elemental calcium is not at all the same thing as taking four 500 mg Tums pills a day. One 2000 is not like the other 2000 and that difference is a source of endless confusion.

See, you can't buy pure calcium in a store. Calcium is too reactive. You buy it in the form of calcium salts: calcium carbonate or calcium citrate or calcium lactate. Each form breaks down in the body to yield the purer calcium. A 500 mg calcium carbonate pill contains 40% calcium, and this 40% portion is referred to as elemental calcium.

Perhaps you already see the confusion. Say that your RDA is for 1500 mg of calcium. You go out and buy three 500 mg calcium carbonate. Do you have enough calcium to meet your dairy needs? Nope, sorry. RDAs are measures of elemental calcium. Your three calcium carbonate pills yielded only 600 mg of elemental calcium. You're not even to half your need. It's worse with other forms. Calcium citrate is only about 20% elemental calcium. You'd need twice as many same sized pills to equal the same calcium need.

Let's cut through the confusion. and go back to the question from the lady who wants to add another 500 mg calcium pills to the three she already takes that provide 1500 mg of calcium. She's buying 2000 mg of calcium, but only 800 mg of elemental calcium. A women over the age of 50 requires 1200 mg of elemental calcium. So she's not in danger of overdosing; she not even getting her full RDA from supplements, so she better hope that she is getting some extra calcium from milk or other foods.

Is she at risk for milk-acidity syndrome from that 2000 mg of calcium pills? Again, no. She would have to consume regularly 2000 mg of elemental calcium. That's 5000 mg of calcium carbonate pills. That's too much. Put a warning flag on taking ten pills a day.

The RDA is expressed in elemental calcium. The warning dose for milk-alkali syndrome is expressed in elemental calcium. But the package amount on a calcium supplement is a higher total amount, only 20-40% of which is elemental calcium. Confusion in a bottle.

The only good part of the confusion is that the way it's arranged, you're not likely to wind up taking too much calcium at any time. And unless you happen to have existing problems that can be made worse by excess calcium, hypercalcemia or milk-alkali syndrome are not high priority worries.

Get enough calcium. Watch your doses. And don't worry about exotic syndromes.

Soluble Calcium Supplement

Steve Ford writes in the UK Nursing Times that a soluble calcium supplement, a calcium supplement that comes in dissolving tablet form rather than as a hard pill, is now available in the British market.

A widely prescribed calcium and vitamin D supplement has been made available in a new dissolvable formulation.

Adcal-D3 Dissolve is indicated as an adjunct to specific therapy for osteoporosis and in situations requiring therapeutic supplementation of malnutrition.

It is available in handy tubes containing 14 effervescent tablets. Four tubes will be packaged together at a basic NHS price of £4.99.

Calcium tablets were known in the past to have poor dissolving abilities. They also passed into the bloodstream from the intestines in lower than optimal dosages. Many articles have been written over whether calcium citrate absorbed better than calcium lactate or calcium carbonate, for example.

Most tablets are better today and standard calcium carbonate tablets are so cheap and come in such large doses that they should be effective for most. Many pills are also chewable, including pills such as Tums, which is mostly calcium.

However, getting the calcium into liquid before it hits the stomach would help those, especially the elderly, who have more difficulty getting calcium to absorb properly. That's why the effervescing pills (i.e., pills like Alka Seltzer tablets) would be helpful.

I've also found some liquid calcium solutions in the U.S., although I don't know anything about them or their usefulness.

One potential warning. A New Zealand study of elderly women (Bolland MJ, Barber PA, Doughty RN, et al. "Vascular events in healthy older women receiving calcium supplementation: randomized controlled trial." BMJ 2008; DOI:10.1136/bmj.39440.525752.BE. www.bmj.com) found - to the utter shock and consternation of the doctors involved - that "cardiovascular events over five years: death, sudden death, MI, angina, other chest pain, stroke, transient ischemic attack, and a composite end point of MI, stroke, or sudden death" appeared to increase in the group given calcium supplements. When other factors were added in, however, the differences were less pronounced. The study included only 61 women given the calcium supplements, which were given in a higher dose and for a longer time. In addition, at an average age of 74 the women were much older than the usual group studied. For all these reasons, none of the doctors is considering this a definitive study. However, if you are elderly and at a risk for a cardiovascular event, talk to your doctor before starting on a soluble calcium supplement.

You Need More Vitamin D with Your Calcium

Earlier claims that calcium could prevent or even cure osteoporosis are now thought to be overblown. That doesn't mean that calcium is not important or that Americans, especially women, are getting sufficient calcium in their diets. All studies I've seen suggest that woman of all ages, from teens to seniors, are short on calcium.

It's true that you don't need to eat dairy products to get calcium in your diet. It's also true that without dairy products, most people find that the vegetable sources of calcium are not their favorite foods to eat in large quantities.

And large quantities are necessary. The National Academy of Sciences, from whom the following chart is taken, raised its estimates for the recommended amounts of calcium.



It's even worse than that. Calcium is no good unless your body can process it properly. One way to help your body do that is to take Vitamin D along with the calcium. Why? The National Osteoporosis Foundation (NOF) says:

The relationship between calcium absorption and vitamin D is similar to that of a locked door and a key. Vitamin D is the key that unlocks the door and allows calcium to leave the intestine and enter the bloodstream. Vitamin D also works in the kidneys to help resorb calcium that otherwise would be excreted.

And the amount of recommended Vitamin D has also been increased.

According to NOF recommendations, adults under age 50 need 400-800 IU of vitamin D[sub]3[/sub] daily, and adults age 50 and older need 800 – 1,000 IU of vitamin D[sub]3[/sub] daily. Vitamin D[sub]3[/sub] is the form of vitamin D that best supports bone health. It is also called cholecalciferol. Vitamin D can also be obtained from fortified milk, egg yolks, saltwater fish, liver and supplements.

If you do want to supplement your calcium, a calcium + Vitamin D pill is helpful. You don't have to look for a pill that contains the entire recommended amount if you are getting a good amount already in your diet. Nor do you have to take the calcium and the vitamin D in one pill. A separate Vitamin D pill or just getting daily sunshine on your bare skin will give you the Vitamin D you need.

On the other hand, there's no need to pay lots of money for Vitamin D pills when you can find calcium + D pills for about the same price as calcium alone. They're a good investment. Remember that store brand pills from major supermarkets, discount stores, and pharmacies should be as good as brand name pills and for much less money.

While most people have too little calcium, true Vitamin D deficiency is rare, about 1 in 5000 people. However, it can be ten times as prevalent in the northern states where people can't get their bare skin into the skin for long periods. If you're not getting into the sun, especially if you're elderly, a Vitamin D supplement is a wise idea no matter how much calcium you eat.

Constipation - The Other Intestinal Ailment

I seldom talk about constipation here. Diarrhea is one of the major symptoms of lactose intolerance, after all, and even some with dairy allergies or hypersensitivities may suffer from it. Some babies with a cow's milk protein allergy may indeed have constipation as a symptom, but it's rare in adults.

That doesn't mean that constipation can be ignored. Just as I warn that diarrhea may have hundreds of causes, so can constipation. And some of those are relevant to the way many of us live our lives.

An article by Kay Ledbetter for AgNews, a publication of the Texas A&M University System Agriculture Program, notes that older adults especially may be victims of constipation, with some extremely serious complications.

Constipation can account for some of the cases of delirium in older adults, causing symptoms similar to those of Alzheimer's disease, said Andrew B. Crocker, [Texas Cooperative] Extension gerontology specialist.

Nearly everyone becomes constipated at one time or another, Crocker said. But older adults may have more bouts due to lack of exercise, diets low in fiber, not drinking enough liquids and taking more prescription medications.

Most of the time it is not serious, he said. However, sometimes it can cause agitation, aggression and combativeness in older adults.

Crocker also mentioned that a variety of medication may have constipation as a side effect.

Some medicines may lead to constipation. These include some drugs used to treat depression, antacids containing aluminum or calcium, some allergy medicines, some high blood pressure drugs and some drugs used to treat Parkinson's disease.

Many people who do not drink milk do use antacids as a cheap and effective way of supplementing their calcium intake. It's not clear from the article which allergy medications are a problem, but you can check any you take with your doctor of pharmacist.

The route around constipation? Fiber and fluids.

Add fiber to the diet by eating more fresh fruits, vegetables and more whole-grain cereals and breads. Dried fruit such as apricots, prunes and figs are high in fiber. Add small amounts of unprocessed bran to baked goods, cereals and fruit. This may cause bloating and gas for a few weeks. Make diet changes slowly to allow the system to adapt.

Be sure to get enough fluids. Drinking lots of water and juices helps some people get back to regular bowel movements.

Stay active. This is important for overall health too.