6

CREATING A MARKET VERSUS PROVIDING A CURE

“Once a upon a time, drug companies promoted drugs
to treat disease. Now it is often just the opposite.
They promote diseases to fit their drugs.”

—Marcia Angell, M.D., former editor in chief
of the New England Journal of Medicine and
author of The Truth about Drug Companies

LET’S FACE IT: DRUG companies are driven by the goal of generating dollars, and they are committed to doing whatever needs to be done to get their drugs to market. And once a drug is on the market, they will do just about anything necessary to sell it to physicians and the public through manipulation, hiring the right experts, and spending enormous amounts of money on advertising campaigns and on inducements to doctors to prescribe it. In their world, money is not everything; it is the only thing.

The ideal for a drug company would be to develop a drug that could address a condition everyone has and then convince doctors and the public that this drug approach is the only way to deal with the condition. Much has been written about the pharmaceutical industry’s goal of turning us all into patients by using its influence to narrows the limits of what is considered “normal.” Perhaps the best examples of this approach were convincing doctors that the natural process of menopause was in fact a “disease” requiring medical treatment in the form of hormone replacement therapy (HRT); convincing doctors that osteoporosis must be treated with drugs so as to prevent hip fractures; and convincing them that lowering cholesterol levels with statin drugs is an effective way to increase life expectancy by preventing heart disease in the general public (this last topic is discussed in Chapter 7).

WOMEN AS GUINEA PIGS

In 1966, Robert A. Wilson, M.D., introduced, in his book Feminine Forever, the theory that menopause is an estrogen deficiency disease caused by the normal decline of estrogen with aging, and that it needs to be treated with estrogen to compensate for this decline. According to Wilson, without estrogen replacement therapy, women are destined to become sexless “caricatures of their former selves…the equivalent of a eunuch.”

Although menopause is a natural process—the term simply denotes the cessation of menstruation in women—Wilson’s theory of menopause as a disease became the dominant medical view until about 2002. In that year, the National Institutes of Health (NIH) halted a major clinical trial designed to help settle the debate over whether HRT benefits postmenopausal women. This study, the Women’s Health Initiative (WHI), concluded that the risks of taking combined estrogen and progestin outweighed the benefits; the therapy increased the risk of stroke, coronary heart disease, and breast cancer. The findings that led researchers to pull the plug early on WHI included links between HRT and:

Once the awareness of the dangers of HRT increased, many doctors and the public became aware of the other studies reporting similar alarming statistics. For example, HRT not only stimulates the growth of invasive breast cancers but also makes it harder to spot the potentially deadly tumors on mammograms; HRT doubled the risk of developing Alzheimer’s disease; and HRT increased the risk of life-threatening blood clots.

The WHI was viewed as a major revelation of the risks and inefficacy of HRT, but in reality this study and others to follow only confirmed was what already known from previous studies about the dangers of these synthetic versions of natural hormones.2, 3, 4, 5, 6 A year or so before WHI was halted, I spoke to at least 400 M.D.s about natural approaches to menopause, at a medical conference. Part of my presentation included sharing the facts on HRT. I could see from the reaction of my audience that the information was not being well received, and during the question-and-answer period it was quite apparent that I had hit a very sensitive nerve. I simply shared with these doctors that when all the studies are examined collectively, it could be concluded that HRT was associated with as much as a 30 percent increase in the risk of breast cancer and that there was little (if any) protective effect against heart disease. Interestingly, at that time—2001—most of the studies linking HRT to breast cancer were conducted in Europe. In comparison, up to 2001 only a few studies in the United States showed that HRT increased the risk of breast cancer. The difference in the link between HRT and breast cancer in the early studies raised some interesting questions for me. Are American researchers biased? Some studies of American women showed no increased risk of breast cancer: was this outcome due to the fact that American women are already at a high risk for breast cancer? Also, why are American researchers and doctors so defensive about the link to breast cancer found in the European studies?

I have lectured to medical doctors for more than 20 years. In general, my presentations have been very well received. But the response that I elicited with this lecture was unlike any other. The doctors bristled when I presented evidence that HRT was not all it was cracked up to be. Why this reaction? I realized that most of these doctors, like most other doctors in the United States, had been enthusiastically recommending HRT to their female patients for many, many years. No well-intentioned researchers or physicians want to admit that a drug that they have been strongly supporting could be irrefutably linked to a dreaded disease such as breast cancer and to an increased risk of death from cardiovascular disease.

The doctors had been influenced by marketing and “conventional wisdom” rather than science. There was absolutely no solid clinical evidence that HRT had a protective effect against cardiovascular disease, but during my question-and-answer session that supposed protection was said to offset the link to breast cancer. Yes, the doctors seemed to agree that HRT does increase the risk of breast cancer, but this risk is offset by a reduction in heart attack and strokes, so life expectancy actually increases. The discussion became very heated when I kept pointing out that the cardioprotective effect of these synthetic hormones was a myth propagated by the drug companies, and that the available clinical studies actually showed an increase in cardiovascular disease with HRT. In the end, we all agreed that the answer to the entire issue would be put to rest by WHI. Of course, when WHI was halted and the results were published, I was quick to point it out, in an e-mail to the sponsors of the conference, that HRT actually increased strokes by 41 percent and heart attacks by 29 percent. In sum, HRT never had any real benefit other than relief of menopausal symptoms—and such relief is easily attained, without risk, through appropriate dietary, lifestyle, and supplemental strategies.

WHY IS HRT STILL BEING PRESCRIBED?

As damning as the results are, from WHI as well as from other studies on the long-term effects of HRT, it is a sad fact that approximately 30 million prescriptions for HRT were still being filled each year after 2002. That represents only about a 50 percent reduction compared with the year 2001 (pre-WHI). Why would doctors continue to prescribe HRT? Unfortunately, they are not aware of effective natural strategies to deal with menopausal symptoms or reduce the risk of osteoporosis.

As I tried to illustrate in Chapter 5, the suppression of symptoms is often a path to bad medicine. There is no question that HRT is effective at relieving the symptoms of menopause, but it is the opinion of many health experts (including me) that for most women long-term HRT is rarely justified: the risks outweigh the benefits. The only possible exception are women who are at high risk of developing osteoporosis. In the WHI study women receiving HRT had a 34 percent lower risk of hip fractures—one of the major consequences of osteoporosis. But there are also natural approaches to osteoporosis that can dramatically reduce the risk of this bone disease.

Decrease in Breast Cancer Rates Related to Reduction in Use of HRT

The immediate effect of WHI was a sudden drop in the number of women using HRT. Not surprisingly, there was a parallel sharp decline in the rate of new breast cancer cases.7 Keep in mind that prior to 2002, breast cancer rates in the United States had been climbing steadily.

Prescriptions for the two most commonly prescribed forms of HRT in the United States—Premarin and Prempro—dropped from 61 million written in 2001 to 21 million in 2004. This drop was accompanied by a reduction of 8.4 percent in the annual rate of breast cancer in the United States. The decrease occurred only among women over the age of 50 and was more evident with cancers that were estrogen receptor (ER)–positive. These cancers need estrogen in order to grow and multiply. The speed at which breast cancer rates declined after the announcements regarding WHI may indicate that extremely small ER-positive breast cancers may have stopped progressing, or even regressed, after HRT was stopped. Clearly, this dramatic drop in the breast cancer rate further strengthens the link between breast cancer and use of HRT.

My recommendations for HRT have been consistent for more than two decades. It should consist only of natural “bioidentical” estrogen and progesterone, and it should be used only for menopausal women showing signs of, or having a significant risk of, osteoporosis, or for women who have severe menopausal symptoms that are not responsive to the natural, nonhormonal approach described below. To determine your risk of osteoporosis, and for more information on natural approaches, see Appendix B.

Major Risk Factors for Osteoporosis in Women

   Being postmenopausal

   Being white or Asian

   Premature menopause

   Positive family history

   Short stature and small bones

   Leanness

   Low calcium intake

   Inactivity

   Being nulliparous (i.e., never having borne a child)

   Gastric or small-bowel resection

   Long-term glucocorticosteroid therapy

   Long-term use of anticonvulsants

   Hyperparathyroidism

   Hyperthyroidism

   Smoking

   Heavy alcohol use

DANGEROUS FORMS OF HORMONES

Most women on HRT have no idea that they are taking unnatural forms of estrogen and progesterone. Premarin, for example, consists of forms of estrogen isolated from mare’s urine (the name comes from pregnant mares’ urine) and, all told, more than 200 substances mostly foreign to a human. Animal rights activists have longed claimed that the methods used to produce Premarin cause suffering to the mares. (Premarin is produced and collected at special pregnant mare urine—PMU—farms, and somewhat barbaric methods are involved.) The major health problem for women taking Premarin and other common forms of conjugated estrogens is that they are metabolized in the body to 17-beta-estradiol—the major carcinogenic form of estrogen. Synthetic versions of progesterone, such as megesterol, norethindrone, and norgestrel, used in HRT are perhaps even more problematic than conjugated estrogens.

If HRT is to be prescribed, it should be what is now referred to as “bioidentical” hormone replacement therapy (BHRT). The hormone components of BHRT are structurally identical to the natural forms of estrogen and progesterone produced in the human body. Because bioidentical hormones are natural, they are not patentable—hence, no big drug companies are promoting BHRT. There are some small studies indicating that BHRT is safer than, and as effective as, HRT in relieving menopausal symptoms; but without the promise of a financial windfall it is highly unlikely that the large trials necessary to conclusively show the advantages of bioidentical hormones will ever be conducted. Hence, although theoretically BHRT should be safer and more effective than HRT in long-term studies, the rational approach is to use BHRT only if it is necessary.

NATURAL HORMONE REPLACEMENT THERAPY

Most naturopathic physicians prefer to use a type of estrogen formulation known as triple estrogen, or Tri-Est, along with natural progesterone. Tri-Est provides a combination of the three major natural forms of estrogen: estriol, estrone, and estradiol in a ratio of 80:10:10. Estradiol is the principal estrogen found in a woman’s body during the reproductive years, but it is also the form linked to breast cancer. The estrogen making up 80 percent of Tri-Est is estriol, a form associated with some protection against breast cancer. The concept behind Tri-Est is to provide estrogens similar to those your body produces but to give lower dosages of the stronger estrogens (estrone and estradiol) and higher levels of estriol. In this way, menopausal symptoms are relieved, and you fight osteoporosis and possibly offset the risk of breast cancer. The typical dosage of Tri-Est is 1.25 milligrams (mg) twice a day to treat mild to moderate symptoms; on 2.5 mg twice a day for moderate to severe symptoms.

Tri-Est and other natural combinations of estrogens are available by prescription through compounding pharmacies (pharmacies that compound or make the drugs on the premises). To find a compounding pharmacy in your area, and for more information, contact the International Academy of Compounding Pharmacists, www.iacprx.org, 1-800-927-4227.

If your doctor is averse to prescribing natural hormones from a compounding pharmacy, there are a number of bioidentical forms of estradiol available, including Estrace, Estrogel, Estraderm, Vivelle, Climara, Alora, Esclim, Orthoest, Ogen cream, Vagifem cream, and Estring. My recommendation if you are using one of these products, is to choose the topical cream or patch version. Applying estradiol to the skin is preferable to taking it orally, for several reasons, but primarily because a skin application appears to be considerably safer. This method more accurately approximates a woman’s own natural estrogen secretions by delivering estradiol into the bloodstream in a slow, sustained manner and avoiding rapid breakdown by the liver.

The preferred progesterone is micronized natural progesterone. “Micronized” means that the hormone has been reduced to very small particles, which are easier to absorb. Micronized progesterone is available in tablets (e.g., Prometrium) as well as in creams. Avoid synthetic progestins such as megestrol, norethindrone, and norgestrel, as well as medroxyprogesterone acetate (e.g., Provera). Again, topical preparations are generally preferred.

NONHORMONAL APPROACHES TO MENOPAUSAL SYMPTOMS

The most common complaints during menopause are hot flashes, headaches, vaginal atrophy, frequent urinary tract infections, cold hands and feet, forgetfulness, and an inability to concentrate. Of these symptoms, hot flashes deserve the most attention. A hot flash is typically experienced as a feeling of intense heat with sweating and rapid heartbeat, and may last from two to 30 minutes. In the United States, 65 to 80 percent of menopausal women experience hot flashes to some degree. In contrast, studies of menopausal women in many traditional cultures throughout the world, and in Japan, have found that most of these women will pass through menopause without hot flashes. In addition, osteoporosis is extremely rare, despite the fact that the average woman in many traditional societies lives longer after menopause than women in the United States. Here are some effective natural approaches for dealing with hot flashes.

Also, you can choose one or more of the following:

Tapering Off HRT

If you elect to discontinue HRT in favor of the natural approach, the best (i.e., the most comfortable) method is to follow the dietary and supplementation strategies above for two weeks and then reduce the dosage of HRT by half. Continue at this half dosage for one month, then cut the dosage in half again by taking it every other day for another month before discontinuing it entirely.

WHAT ABOUT OSTEOPOROSIS DRUGS?

Osteoporosis means “porous bone.” It involves both the mineral (inorganic) components of bone and the nonmineral components (organic matrix, composed primarily of protein). Bone is dynamic living tissue that is continually being broken down and rebuilt, even in adults. Osteoporosis occurs when more bone is breaking down than is being formed.

Osteoporosis currently affects between 13 percent and 30 percent of all postmenopausal women in the United States, depending on what criteria you use to define it. The most serious consequence of osteoporosis is fractures. It is estimated that osteoporosis causes approximately 1.5 million fractures every year. Of these, 250,000 are fractures of the hip. Despite the considerable advances in medical care, as many as 20 percent of women with hip fractures die within a year of the fracture, and 25 percent require long-term nursing care. Approximately half the women who suffer from a hip fracture are unable to walk without assistance. Obviously, one important goal in dealing with osteoporosis is to avoid hip fractures.

Though osteoporosis is largely a disease of diet and lifestyle, the drug industries have developed drugs for it. One class of drugs, the bisphosphonates, work by destroying a type of bone cell (osteoclast) responsible for remodeling bone, leading to an overall decrease in the breakdown of bone. Examples of bisphosphonates include Fosamax, Aredia, Boniva, Actonel, and Zometa.

In addition to the bisphophonates, there is a newer class of osteoporo sis drugs, selective estrogen modulators (SERMs). The first of these drugs to be marketed was Evista (raloxifene). The SERMs work like a weak estrogen to stop bone loss. But since (unlike estrogen) they do not stimulate the breast or uterus, they are not associated with an increased risk of cancer. Interestingly, soy isoflavones act in a similar manner to reduce bone loss, but without side effects.

MARKETING FEAR

The evolution of the bisphosphonate empire began with Merck’s Fosamax in 1995. As with many other blockbuster drugs, the growth in sales of Fosamax is a case study in effective manipulation by the drug companies. Apparently, the first step was a new definition of osteoporosis by the World Health Organization (WHO). No doubt led by experts who were sponsored by drug companies, WHO defined “normal” bone density as that of a 30-year old woman. Since there is a natural decline in bone density associated with aging, this new criterion immediately defined 30 percent of postmenopausal women as having osteoporosis.

Next, even before Fosamax reached the market, Merck was priming the pump by subsidizing the distribution of machines to test bone density. The strategy was simple. With the new guidelines in place and more accessible testing methods available, more prescriptions for Fosamax would be written. Merck worked hard to increase awareness (i.e., fear) of osteoporosis and impel women to get free bone density tests offered by local hospitals, clinics, and mobile facilities. The strategy worked perfectly. By 2003, Americans spent $1.7 billion annually on Fosamax.

Are such drugs effective? And what about their safety? Before answering these questions, I think it is important to answer the question, “Does testing bone mineral density help to prevent hip fractures?” The answer is quite interesting because once again it is contrary to conventional wisdom. According to a careful review of the literature and the results of a very large study, there is no correlation between testing alone and the prediction or prevention of fractures.23 It seems that the test is not sensitive enough, because bone density is not the only risk factor that contributes to fractures. In fact, osteoporosis accounts for only about 15 to 30 percent of all hip fractures in postmenopausal women. About one-third of all women who fracture a hip have normal bone density, and the rest are somewhere in between. Other important risk factors for hip fracture are a small frame, a low body mass index (BMI), long-term glucocorticoid therapy, cigarette smoking, excess alcohol intake, diabetes, family history, and conditions that increase the risk of falling, such as poor balance and muscular weakness.24 For many patients, efforts to prevent falls by improving diet, lifestyle, balance, and muscular strength maybe more important in preventing fractures than increasing bone strength is.25

DETERMINING BONE MINERAL DENSITY

Bone mineral density (BMD) testing alone may not be a good predictor of fractures, but it is a great way to increase awareness of and establish a diagnosis of osteoporosis. There are several techniques for measuring BMD, but the gold standard is dual-energy X-ray absorptiometry (DEXA). Other methods of assessing bone mass include computerized tomography (CT) scans, ultrasound of the heel, and radiographs, but none of these are as optimal as DEXA for diagnosis and follow-up.

In addition to providing the most reliable measurement of bone density, DEXA requires less radiation exposure than a conventional radiograph or CT scan. Usually, DEXA is used to measure the density of both the hip and the lumbar spine. The hip is the preferred site for BMD testing, especially in women older than 60, because the spinal measurements can be unreliable. Although peripheral DEXA sites are accurate, they may be less useful because they may not correlate as well with fracture risk and BMD at the hip and spine. The guidelines for indications for BMD testing established by many reputable and independent organizations are as follows:

  • image Secondary causes of bone loss (e.g., steroid use, hyperparathyroidism)
  • image Radiological (X-ray) evidence of osteopenia (insufficient bone mineral density)
  • image All women 65 years and older (not only for a diagnosis, but also as a historical reference point for future comparisons)
  • image Younger postmenopausal women with fractures due to fragile bones since menopause, low body weight, or family history of spine or hip fracture

Results of BMD tests are reported as standard deviations—either a Z-score or a T-score. The Z-score is based on the standard deviation from the mean BMD of women in the same age group. The T-score is based on the mean peak BMD of a normal, young woman. The criteria established by WHO for the diagnosis of osteoporosis use T-scores: a score below-2.5 is associated with osteoporosis. The classification of osteopenia signifies a BMD that is between normal and osteoporosis.

Interpretation of Bone Mineral Density Scores

BMD = bone mineral density; SD = standard deviation.

Status

T-score

Interpretation

Normal

Above-1

BMD within 1 SD of a young normal adult

Osteopenia

Between-1 and-2.5

BMD between 1 and 2.5 SD below a young normal adult

Osteoporosis

Below-2.5

BMD is 2.5 SD or more below a young normal adult

FOSAMAX—WHAT IS THE REAL BENEFIT?

Merck’s introduction of Fosamax coincided with the publication of the Fracture Intervention Trial, a study funded by Merck.26 At first glance the claims made in Merck’s advertisements for Fosamax were quite impressive: Merck claimed that, compared with a placebo, Fosamax reduced the rate of hip fractures by 50 percent. But if you take a closer look, the numbers do not seem so rosy. First of all, the women in the study were high-risk women who had a history of a fracture due to osteoporosis. Next, when you look at the absolute number of hip fractures that occurred during the four-year trial, the perspective changes dramatically. Only two out of 100 women in the placebo group had a hip fracture during the trial, compared with one woman out of 100 in the Fosamax group. In other words, 98 women out of 100 in the Fosamax group would have fared just as well on a placebo. It is true that for individuals who are at a very high risk, bisphosphonate therapy may offer some benefits; but I am not convinced that these benefits cannot be obtained even more effectively through nondrug measures. In fact, if you look at clinical studies done with vitamin D, calcium, and vitamin K2 it appears that the natural approach is far superior.

Keep in mind that women at high risk are a much smaller group than the tens of millions of women identified by the expanded definition of low bone density. In fact, bisphosphonates are prescribed just as often for women with osteopenia (bone mineral density that is lower than normal, but not low enough to be classified as osteoporosis) as for women with osteoporosis, even though there is no correlation between osteopenia and the risk of a hip fracture. Bisphosphonates and Evista have shown no effectiveness in the treatment of osteopenia, and are not indicated for such treatment, despite considerable efforts by the drug companies to convince doctors otherwise.27

So why are doctors prescribing bisphosphonate or Evista (or both) for millions of women with osteopenia in the United States, when the research does not show any clear benefit? Obviously, the reasons are the fear that “low” bone density creates, the doctors’ desire to do something, and the effective advertising and marketing of these drugs. It is little wonder that sales are so high. These drugs, however, are associated with significant side effects. Instead of relying on a drug to reduce the risk of osteoporosis and hip fracture, the more rational approach would be to focus on diet, lifestyle, and supplements.

SIDE EFFECTS OF BISPHOSPHONATES AND EVISTA

Granted, my patient population may have been a bit skewed because the patients came to see me to help them get off their prescription drugs, but the patients I saw on bisphosphonates complained mightily about the side effects. In fact, I cannot recall anyone who really tolerated these drugs. Most of the side effects are mild: they include minor digestive disturbances such as heartburn, diarrhea, and flatulence; muscle and joint pain; headaches; and allergic reactions. However, early on the risk of severe damage to the esophagus was not known, and I did have a few patients who had suffered this serious side effect as well as more debilitating muscle pain. It is very important that anyone taking a bisphosphonate remain standing or seated upright for 45 to 60 minutes after taking the medication.

Bisphosphonates have also been associated with severe bone destruction (osteonecrosis) of the jaw. This side effect is most often seen in cancer patients or those undergoing dental work to eliminate potential sites of infection.

The most serious side effect for Evista and other SERMs is the formation of clots that can block veins or lodge in the lungs or heart. Though these side effects occur only in about one out of 100 patients treated with Evista, women treated with Evista are more than twice as likely to develop clot-related disease as women taking a placebo. More common side effects of Evista include difficult, burning, or painful urination; fever; increased rate of infections; leg cramps; skin rash; swelling of hands, ankles, or feet; and vaginal itching. Less common side effects include body aches and pains; congestion in the lungs; decreased vision or other changes in vision; diarrhea; difficulty in breathing; hoarseness; loss of appetite; nausea; trouble in swallowing; weakness.

A RATIONAL APPROACH TO OSTEOPOROSIS

Normal bone metabolism depends on an intricate interplay of many genetic, nutritional, lifestyle, and hormonal factors. A rational approach to osteoporosis involves reducing as many risk factors—that is, as many causes—as possible and at the same time incorporating as many causes; dietary and lifestyle factors that are extremely important in lowering the risk of osteoporosis. For example, smoking and excessive alcohol and caffeine increase the risk of developing osteoporosis, and regular exercise reduces the risk. In fact, numerous studies have clearly demonstrated that physical fitness is the major determinant of bone density. Physical exercise consisting of one hour of moderate activity three times a week has been shown to prevent bone loss and actually increase bone mass in postmenopausal women.28

Perhaps the most important dietary recommendation is to eat more green leafy vegetables and vegetables from the cabbage family, including broccoli, brussels sprouts, kale, collards, and mustard greens. These foods, as well as green tea, offer significant protection against osteoporosis. They are a rich source of a broad range of vitamins and minerals that are important to maintaining healthy bones, including calcium, vitamin K1, and boron. Vitamin K1 is the form of vitamin K that is found in plants. A function of vitamin K1 is to convert inactive osteocalcin to its active form. Osteocalcin is an important protein in bone. Its role is to anchor calcium molecules and hold them in place within the bone. A higher intake of green leafy vegetables may be one of the key reasons that a vegetarian diet is associated with a lower risk of osteoporosis. Although bone mass in vegetarians does not differ significantly from that of omnivores in the third, fourth, and fifth decades of life, there are significant differences in later decades. These findings indicate that the decreased incidence of osteoporosis among vegetarians is due not to increased initial bone mass, but rather to decreased bone loss.29, 30

Here are some other important dietary considerations for preventing osteoporosis:

DOES MILK PREVENT OR CAUSE OSTEOPOROSIS?

Although numerous clinical studies have demonstrated that calcium and vitamin D supplementation can help prevent bone loss, the data are inconclusive with regard to any link between a high dietary calcium intake from milk and the prevention of osteoporosis and bone fractures. In fact, the current available data indicate that frequent consumption of milk actually increases the risk of osteoporosis. Reviewing the statistics from the Nurses’ Health Study, which involved 77,761 women, researchers found that those who drank two or more glasses of milk per day had a 45 percent increased risk of hip fracture, compared with women who consumed one glass or less per week.37 In other words, the more milk a woman consumed, the more likely she was to fracture a hip. This negative effect may turn out to be due to the vitamin A added to milk (at higher levels, vitamin A, but not beta-carotene, may interfere with bone formation). Interestingly, if you look at the rate of osteoporosis worldwide, it is considerably higher in countries where milk intake is highest.

Important Nutritional Supplements for Healthy Bones

A QUICK AND EASY WAY TO REDUCE HEALTH CARE COSTS AND EXTEND LIFE

Considerable attention is focused on the need for increased levels of calcium, but most experts now agree that much greater attention should be focused on vitamin D. Its metabolic products not only stimulate calcium absorption but slow bone loss, increase bone formation, and reduce the risk of falling. It is estimated that by simply supplementing the diet with 1,000 to 1,200 mg of calcium and 800 to 1,000 IU of vitamin D more than half of all hip fractures could be prevented. The economic consequences of such a policy would be enormous: over a five-year period, more than 734,000 hip fractures could be avoided and more than $13.9 billion in health care costs could be saved. In addition, an analysis of studies with vitamin D showed that the participants who took vitamin D supplements had a 7 percent lower risk of death during the study period than those who did not.49 Of course, this result is not surprising. It is now known that virtually every cell in our body has receptors for vitamin D and that vitamin D is not just a vitamin. It also performs very powerful hormonal activities and has protective effects against certain cancers (particularly cancer of the breast and prostate), autoimmune diseases such as multiple sclerosis and type 1 diabetes, and heart disease.50 So, lack of vitamin D would affect far more than just our bones. Can you imagine the marketing that a drug company would put behind a drug that was shown to increase your chance of living longer? Sadly, this benefit of vitamin D has gone largely ignored because there is no financial reward for getting the word out.

A recent study published in the American Journal of Clinical Nutrition has added another major benefit for vitamin D and also provides an explanation for its promotion of longevity.51 Vitamin D may slow aging by increasing the length of telomeres. A telomere is the section of a chromosome that shortens each time a cell replicates. The shorter the telomere gets, the more it affects gene expression. The result is cellular aging. In this study, scientists considered the effects of vitamin D on the length of telomeres in white blood cells of 2,160 women aged 18 to 79 years. The higher the vitamin D levels, the longer the telomere. In terms of the effect on aging, there was a five-year difference in telomere length in those with the highest levels of vitamin D compared with those with the lowest levels. Obesity, smoking, and lack of physical activity can shorten the telomere, but the researchers found that increasing vitamin D levels overcame these effects. What this five-year difference means is that a 70-year-old women with higher vitamin D levels would have a biological age of 65 years.

Troubling Statistics on Vitamin D Deficiency

40 percent of the U.S. population are deficient in vitamin D.

42 percent of African-American women of childbearing age are deficient in vitamin D.

48 percent of girls (nine to 11 years old are deficient in vitamin D.

60 percent of all hospital patients are deficient in vitamin D.

76 percent of pregnant women are severely deficient in vitamin D.

80 percent of nursing home patients are deficient in vitamin D.

HOW TO INCREASE YOUR VITAMIN D LEVELS

Since vitamin D can be produced in our bodies by the action of sunlight on the skin, many experts consider it more a hormone than a vitamin. Sunlight changes a compound (7-dehydrocholesterol) in the skin into vitamin D3 (cholecalciferol). It is generally thought that as little as 15 minutes of direct sunlight on the skin can significantly raise vitamin D levels, but recent research has challenged this conventional wisdom. For example, from the latitude of San Francisco northward—or from Buenos Aires southward—for three to six months of the year, no amount of exposure will generate substantial vitamin D in even the palest skin.52

To ensure adequate vitamin D levels, supplementation is warranted, especially for those who live in a high latitude or who get little direct sunlight. There are two major dietary forms of vitamin D: vitamin D2 (ergocal-ciferol) and vitamin D3 (cholecalciferol). Vitamin D2 is the form most often added to milk and other foods, as well as the form most often used in nutritional supplements. Vitamin D3 in nutritional supplements is most often derived from fish liver oil or lanolin. Both D2 and D3 are capable of being converted to active vitamin D in the body. Very few foods naturally contain vitamin D or are fortified. Fish such as wild salmon (360 IU per 3.5-ounce serving), mackerel, and sardines are good sources of vitamin D3. Fortified foods including milk (100 IU per 8-ounce serving), orange juice (100 IU per 8-ounce serving), and some breads and cereals provide D2. The reason I have specified wild salmon is that the vitamin D content of farmed salmon is 75 percent less than that of wild caught salmon from Alaska.52

Recently, most experts have been recommending a daily intake of 800 to 1,000 IU of vitamin D. Although vitamin D conceivably has the potential to cause toxicity, dosages in the range of 800 to 2,000 IU per day are now recognized as being safe levels.53

The drugs cholestyramine (Questran), colestipol (Colestid), phenytoin (Dilantin), and phenobarbital, and mineral oil, all interfere with the absorption or metabolism (or both) of vitamin D. So, you will need to take vitamin D at the higher recommended dosage, 2,000 IU daily. The same is true if you are taking corticosteroids such as prednisone, because they increase the need for vitamin D. Vitamin D supplementation must be used with caution if you are taking digoxin (Lanoxin®) and thiazide diuretics: in that case, do not take more than 400 to 800 IU of vitamin D daily without consulting your physician.

FINAL COMMENTS

I think it makes sense for women to have a baseline test of bone density. Though these tests are being abused—in the sense that they simply serve to justify prescribing a drug—they do provide information that is valuable in bolstering bone health through diet, lifestyle, and nutritional supplements. Many medical associations recommend having this baseline test done at age 65, but my feeling is that it makes even more sense when women are in their thirties and forties, because the natural approach to building bone is even more effective then. The test is useful for men only if there is some factor that may predispose them to osteoporosis, such as long-term use of prednisone or another corticosteroid.

The test assesses how much bone mass you currently have. It will tell you whether you need to make an even more serious effort to maintain your bone. Information from the test can be used in later years to measure the rate of bone loss. Of course, a bone density test may also tell you that you already have osteoporosis.

Once you know your current bone density, the next step is to monitor how fast your bones are breaking down. The easiest way to do this is to measure the products of bone loss in the urine. The test I recommend is the Osteomark-NTX. It can provide valuable information on the rate of bone breakdown, and you should ask your doctor for it.