An Apple A Day

The results of a recent trial were disappointing to some but I think that disappointment is unwarranted. Subjects were given 1000 iu of D3 daily. This dose did not reduce their body weight. That would have been nice for those wanting to lose weight. However, the subjects did significantly lower body fat and abdominal fat, both of which are more meaningfully connected to your health. Also, as many of you I am sure recognize, 1000 iu/day is pathetic. Just to reach a normal blood level, most of my patients have to take a minimum of 3-5,000 iu/day. So, an adequate dose might well have done more. That would have been in keeping with numerous other studies linking elevated weight with low vitamin D status.

A recent study in DERMATO-ENDOCRINOLGY authored by vitamin D pioneer William Grant adds to the evidence linking low vitamin D with autism. Children living in sunnier states developed autism roughly half as often as children living in the cold, dark northern states. With their darker, less vitamin D efficient skin, African Americans in the northern states were 40% more likely to be diagnosed with autism than white children in the same states, which parallels their reduced blood levels of vitamin D.

A study was just published with exclamatory headlines warning about vitamin D and calcium raising the risk of kidney stones. They studied the blood and urine of 163 healthy, postmenopausal women for a year. Investigators gave the women from 0-4,800 iu of vitamin D and raised their calcium to 1,200 - 1,400 mg/day. 1/3 of the women had high levels of urinary calcium and some had elevated blood levels.

That would seem scary, except it isn’t. First, no one actually had a kidney stone or other trouble. More important to me is a much bigger study, involving more than 10 times as many women over a 10-20 times longer time span, also showing no kidney stones and no otherwise unaccounted for calcium elevations on blood work. That bigger study is my clinical practice.

Maybe this is because I insist that my patients drink enough water. Dehydration is the major factor leading to kidney stones and calcium is notoriously insoluble.

It may also be another example of our ignorance about calcium metabolism. For decades, the standard medical advice for patients who had a common calcium-based kidney stone was to avoid calcium. Then someone actually did a study instead of just making it all up, and found that low calcium intake was associated with INCREASED risk of kidney stones.

Another contradictory example can be seen in the disease called hyperparathyroidism. More common than once thought, people with hyperparathyroidism have high calcium levels which can potentially become lethal. Many feared that giving these patients vitamin D would make things worse. Turns out that taking vitamin D does not raise calcium levels in patients with hyperparathyroidism. In fact, in many of these patients, taking vitamin D lowers calcium and helps the patient otherwise.

Bottom line - get as much calcium as you can from food, use calcium supplements to make up for what you can’t eat, take lots of vitamin D (targeting a blood level over 50) and DRINK enough WATER so that your urine just slightly tints the water in your toilet.

If you read about vitamin supplements you must be confused. Actually, it would be hard not to be. Vitamins are, by definition, essential to health. Studies of hundreds of millions of people confirm that truth. However, a rash of recent studies have linked taking vitamin supplements to higher rates of a variety of diseases, especially cancer. What’s up?

The fundamental problem is bad research. This bad research is the consequence of poor understanding, plus the difficulties inherent in designing and conduct nutritional studies that apply to the real world. The best examples of the faults in these nutritional studies are probably those dealing with folic acid and vitamin E.

Many studies show that dietary folic acid reduces the risk of many diseases, particularly cancer. The prevention of congenital spinal malformations is the main reason our food supply has been fortified with folic acid for decades. Surveys of the American population show that this approach works. That is the simple part. The confusing part is that some studies have shown an increased risk of cancer with folic acid supplementation, while others have shown that folic acid lowers the risk of the very same cancers.

As many of you have heard me explain following your own blood testing, nearly 20% of us have a genetic inability to convert folic acid to its metabolically active form. Those individuals among us need to take a special form of folate. If they take the common, most widely available kind of folic acid, not only does it not help, it seems to cause problems consistent with the unhappy research findings. After MERCK, which holds a patent on this form of folic acid, allowed others to use it, I had it added to my multiple vitamin. Very few multiple vitamins contain this form of folic acid, as it is more expensive. Two months ago I read an editorial in a major medical journal wherein a couple of prominent experts pointed out that negative studies on folic acid in diabetics had neglected to address this issue. Their opinion, with which I am in complete agreement, was that these studies were fundamentally flawed and almost certainly drawing incorrect conclusions as a consequence.

Vitamin E has also taken a lot of heat due, to a similar lack of understanding. Most of the vitamin E you can buy in supplements comes as alpha tocopherol. Unless you are a chemist, your brain won’t want to swallow that word or distinguish it from beta, gamma, delta or any other tocopherols. It is not even that simple, because even with all of those tocopherols, an additional class of compounds called tocotrienols are part of the Vitamin E family and seem to be important. Food contains all of these compounds, and it appears that alpha tocopherol might be the least important of all. As one vitamin E researcher wrote, “taking a mixture of vitamin E that resembles what is in our diet would be the most prudent supplement to take”. I would amend that statement to read, “taking a mixture of vitamin E that resembles what would be in an ideal diet and considers your individual needs, would be the most prudent supplement to take”.

A recent survey concluded that very few Americans were low on any vitamins or minerals. While that got significant media attention, the fact that hundreds of studies have shown the opposite, did not. Many of those studies actually measured body levels. That is especially important as estimates from dietary records are woefully misleading. Dietary records are infamously different from the truth of what people really do eat. On top of that, absorption varies tremendously from person to person and even time to time for the same person.

Thankfully, there is evidence that some who write about and study nutrition are thinking more clearly. The “experts” are becoming more expert. Also, those with a better understanding are getting at least some attention for their criticisms.

Positive evidence of the benefits of dietary supplementation continues to accumulate (of course). Recent studies have shown that the brains of people of all ages, from young children to elderly adults, function better beginning just days after starting to take a multiple vitamin. The same holds true of omega-3 supplements. In an example of the complexity of nutrient interaction, vitamin E lowers the rate of prostate cancer but only when taken along with selenium.

Bottom line-

Think critically - If something is vital, many of us need it.

Don’t forget the food - A vitamin pill cannot entirely replace good food.

Don’t go crazy - Take moderate amounts of nutrients as a safety net.

Go crazy if YOU need to - Some people, especially when ill, need much more.

Vitamins vary - Cheap forms of nutrients cost less, but they are usually a waste of money and can be harmful

As you probably know, exercise may well be the single most important health habit. Drinking water, eating well, using supplements properly, avoiding toxins, sleeping, working on your attitude and relationships are all also vitally important. However, even beyond its power to prevent and treat disease, exercise may well provide the greatest wellbeing boost of any of the essential health habits.

Whether exercise is “number one” or not, it is huge though, and getting people to exercise can be an equally huge problem. The number one obstacle for most people is time. Sure, our heritage is to be physically active all day long, sometimes vigorously so. Just as we are omnivorous eaters, consuming just about anything, our bodies need all kinds of physical activity and thrive on the greatest diversity. We need to work on our muscular strength (especially as we get old). We need aerobic activity to strengthen our heart and lungs. Flexibility and balance are also necessary. Our bodies, including our brains, need all of this physical activity, but where can one find the time?

Like many in sports medicine, I am very excited about recent discoveries about one form of exercise that can shorten your time commitment, while simultaneously providing you with even greater benefits than those long, slow, time-consuming physical activities pursued by so many.

This magical form of exercise is called High Intensity Intermittent/Interval Training (HIIT). Many of you will recall the crushingly intense sprint work your coach or PE teacher used to train/punish you with long ago. HIIT is a bit like that, but NOT torturous. In fact, when patients in intensive care with heart disease where given a choice of walking on a treadmill or a HIIT workout, the great majority preferred HIIT.

That’s right, ICU patients encouraged to engage in a workout that would seem to be a good way to kill them off. I am almost as impressed by the fact that these latest studies using very sick hospitalized patients were approved by human subjects committees, as I am with the remarkable impact of the HIIT regimens.

When the first studies came out on this approach less than 10 years ago, they were small but impressive, conducted on young, often already well-conditioned athletes. HIIT seemed like it might prove to be a way for these athletes to kick up their fitness after a layoff, or in the lead up to a big competition. After more and more results came in, showing how efficacious this approach could be, researchers decided to try it out on other populations.

Amazingly, we have now built up research evidence ranging from the basic sciences (cellular and physiological changes) to clinical trials of old and young, fat and thin, trained and out of conditioned individuals. The bottom line: It’s all good.

In only two to three weeks of 2-4 short sessions of HIIT each week, just about every measure we have of fitness improves, often markedly so. It also improves blood tests associated with long-term risk of heart disease, diabetes, cancer and Alzheimer’s. Also, forget the long, slow activity and the “fat burning” heart rate zones you see posted on exercise equipment. HIIT gets fat burning better than low intensity exercise, and keeps it going for hours after your workout ends.

One of the incontestable failings of age is that our maximal oxygen uptake drops year after year, beginning in our late 20s. We just don’t have the aerobic capacity we used to. HIIT has been shown now to improve oxygen uptake, the most essential fuel for our cells, regardless of age, gender or previous fitness.

This is all great news, but it gets better. HIIT, with the rest intervals between the intense exertion intervals, is unlike the sprint training you might have endured long ago, and not just because it is less unpleasant. The only research comparing HIIT to that sprint-sprint-sprint-till-you-drop torment, shows that HIIT actually works better. Yay!

With one exception, I cannot remember any similar wave of research on a specific treatment. That one exception, vitamin D, is an almost perfect comparison. The evidence suggests vitamin D levels are linked to improvements in nearly every human health trouble. Similarly, HIIT does almost everything we have learned that exercise can do. Although there are fewer studies of HIIT than vitamin D, the quality of evidence might actually be even stronger than the vitamin D studies to date, because the of the way HIIT studies can be designed (intervention versus observation).

Okay, so how do you do it? Very simple. Warm up a few minutes (5-10). Then alternate working hard and easy. How long? The easiest way is probably to go hard for a minute and then easy for one minute, repeating that cycle a total of 10 times. Some studies used a four minute hard interval followed by three minutes of easy, for a total of four cycles. We do not know if some duration will prove to be better than another. All the studies, using whatever interval, show that it works. Consequently, I’d say it is up to you.

My son, for example, lives in a high rise building in a big city. He wanted to work out climbing stairs as he does not have any cardio equipment and gyms are extremely expensive where he lives. The plan we worked out was for him to climb up for 4 minutes, which gets him near the top of the 30 stories, take the elevator back down then do it three more times.

You can walk, going faster and then slower. You can do the same with swimming cycling or whatever activity you prefer.

How hard is hard? 90% of your maximal heart rate. Maximal heart rates are very scientific but they can be annoying to use as a measure, because you have to monitor your heart rate and figure out what 90% of MHR is for you. Maximal heart rate is different for different people, men versus women and it changes with age. It also differs by what you are doing.

My advice is to do this by how hard it feels to you. 90% = panting. Go hard enough so that you are breathing heavily and then go easy. As you go through the cycles, you will probably learn that, keeping your effort at the same level of intensity, you are going at a slower pace. That is fine. Do not try to maintain the same pace unless you feel about the same level of exertion. The point is your effort, how it feels to you. Do not thrash yourself. Start out being careful not to push yourself too much, and as you do it for a while you can get a better sense of what your limits are. You do need to approach those limits, to push yourself, to get the maximum benefit from this. If you have any questions about this, please come in to talk about your individual circumstance.

I will add that there are some HIIT regimens that make the hard exertion interval much longer than the easy, recovery interval. I do not like that for anyone who is not already quite fit.

My own experience with HIIT may be of interest. In years past I trained in this way to build fitness, partly because it was closer to the most demanding physical work I did. Refereeing semipro men’s soccer games, at times sprinting to keep up with athletes 20 years younger than I, was not at all like jogging for an hour or two. More recently, as problems leading to my knee surgery became increasingly troublesome, I dropped all of my longer aerobic sessions. My knee just would not tolerate them. I experienced much of the same energized but relaxed sensations of the longer aerobic work, but with considerably less pain in my knee. One conclusion from this is that HIIT can have an important role to play when a person has a chronic or acute joint problem, limiting the stress his/her body can endure.

900 pages and zero thought. That is my summation of the IOM’s new calcium and vitamin D statement. Having been a member of such consensus panels in the past, I am sympathetic to their tendency to fall to the most conservative “lowest common denominator” opinion. However, this document is far from a reasonable scientific assessment. Considering the research they ignored and my clinical experience, I am disappointed for the people who will suffer needlessly.

Go to http://www.grassrootshealth.net/iomquotes if you want to read comments from other scientists. Also, the Vitamin D Council is filing a request under the Freedom of Information Act that IOM release the recommendations submitted to them by vitamin D researchers and Walter Willett from Harvard, all of whom supposedly recommended higher standards than IOM.