Supplements - vitamins and minerals to help our bone health.
What a mine field! The more I dug into this topic, the more conflicting information I found. I got so very confused. I think fueled by a gap, a lag, in what is advised and what emerging research is saying. Will we reveal clarity? Yes, in some instances.
But where we don't, I want you to take this away.
Have the conversation with your health team about them and what specifically is right for you. I say health team because a dietitian may be more up to date with current research and standards for example. Don't assume because they're vitamins and minerals that they are safe and harmless. Have the chat, get the advice...don't assume. Ask them what the current research is saying so you can understand where their advice is coming from. Then decide what course of action is best for you.
Because we are each individual with individual needs. Not only in the way we metabolise vitamins and minerals but in what we eat, our lifestyle and health conditions. What we require to supplement and the amount we take, if any at all.
Supplements 101
Before we dive into the specific supplements that relate to bone health, I though it might be helpful to talk about what a supplement is, measurements & RDI's - because even that can be confusing.
"Dietary supplements are products designed to give you nutrients that might be missing from your diet. They are usually taken as tablets, capsules or powders, or as a liquid drink." (Healthdirect.gov.au). To literally supplement the nutrient gaps you have if what you eat and drink is not giving you enough. Not to take instead of eating the right foods in the right amounts.
With our health and wellbeing becoming increasingly top of mind, with our desire to optimise it for a longer health span, the supplements market is big. "Dietary supplements are the most common type of complementary medicine in Australia, reportedly used by 47% of the population. Vitamins and minerals are particularly popular." (The safety of commonly used vitamins and minerals - Australian Prescriber)
Units of Measurement:
mg, mcg or μg, nmol/L, IU...
Different vitamins and minerals will have different units of measurements. Australia may also measure differently to other countries like the US so if you are reading information from other countries, you may need to 'Google' to convert the measurements.
In Australia, the primary units of measurement for vitamins and minerals are milligrams (mg) and micrograms (mcg), with International Units (IU) sometimes used for fat-soluble vitamins like A, D, and E. Milligrams (mg) represent 1/1000 of a gram, while micrograms (mcg or μg) represent 1/1,000,000 of a gram.
Regulation: Unlike other countries, here in Australia all dietary supplements, to be legally supplied, must be registered and be approved for use by the TGA (Therapeutic Goods Administration). "Supplements, vitamins and complementary medicines are often considered therapeutic goods, regulated as non-prescription medicines by the TGA. This means that they must be compliant with TGA legislation and entered onto the Australian Register of Therapeutic Goods (ARTG) to be legally supplied in Australia." (TGA.gov.au)
Take a look at one of your supplements. The label will have an Aust L number on it. That's the TGA approval number. Can't see it? Then it's not registered and therefore not regulated. Curious? Head here to the ARTG (Australian Register of Therapeutic Goods) to see if it's listed and to find out more about it.
RDI's: Recommended Dietary Intake is the recommendations from health authorities (like the Australian government) for various vitamins and minerals before they are absorbed by the body. The next one is due sometime in 2025/26. That's 12/13 year gap. Your GP and health team will have their sources too, perhaps more up to date with more recent research and recommendations. That's why it pays to ask. RDI's are broad suggested amounts. Think of them as a baseline for 'optimal health'.
This is where supplementing comes into play. When you don't get the RDI's from your diet (what you eat and drink) then dietary supplements may be necessary, depending on your individual situation and needs.
Okay...let's go, diving into the more common vitamins and minerals often included in a conversation with your health care team when it comes to bone health.
Calcium - The Double-Edged Sword
Our bones store 99% of our body's calcium so calcium certainly is important for bone health. Calcium combines with other minerals to form hard crystals giving bones strength and structure. "Bones act like a calcium bank. If there is not enough calcium in your diet, the body will take what is needed from your bones for use in other parts of the body. If this happens, your bone density (bone strength) will gradually decline, and you may be at risk of developing osteoporosis." (Healthy Bones Australia).
But how we keep that reservoir topped up is where the controversy and contradiction creates confusion - it's a double edged sword. We need it, but take too much and it creates problems. Some suggest we don't need to supplement at all for bone health as there is little evidence to support fracture risk reduction. Whilst the other camp says it's helpful.
RDI: For a woman 50+ the Australian RDI is 1300mg* and represents the amount of calcium needed before it's absorbed by our body. *source: www.eatforhealth.gov.au/nutrient-reference-values/nutrients/calcium + Healthy Bones Australia.
Absorption: It's one thing to take calcium (if needed) it's another to absorb it well. As we age, our ability to absorb calcium from what we eat and drink decreases. Absorbability also depends on the type of calcium taken and the nature of the food source. How bioavailable is it? All forms of calcium are not created equally. The most bioavailable forms are Hydroxyapatite and Calcium Citrate.
From a food perspective, "the amount of calcium listed on the Nutrition Facts label of a food product is the measure of calcium in the food, but not necessarily the amount the body will absorb. The amount that is actually absorbed and used by the body is called "calcium bioavailablity." Some foods have higher calcium bioavailability than others. For example, dairy foods have a bioavailability of about 30% absorption so if a food label on milk lists 300 mg of calcium per cup, about 100 mg will be absorbed and used by the body." This comes from The Nutrition Source. There are more examples of foods and their bioavailability detailed in it - fascinating and eye opening.
Side Note: This blew my mind when I found this out. I want to get 'bang for my buck' with what I eat. Bioavailability is something I'll keep on my radar now when looking for foods to eat for my health. How about you? Did you know about this?
Risks & Contradictions:
Some research suggests these are potential risks associated with supplementing calcium:
- Cardiovascular problems - namely hardening of blood vessels with a build up of calcium, trigger blood clots and the likelihood of heart attack.
- Formation of kidney stones.
- Formation of colon polyps.
Some believe the best calcium supplement is none. That there is little evidence to suggest that supplementing prevents bone fracture or helps to increase bone mineral density.
Reducing the Risks:
Think food first. The best way to get your RDI of calcium is in food because when we 'eat our calcium RDI' we do so in small amounts spread over a longer period in the day. Our body is better able to handle that.
Here's a handy list for you that has the amount of calcium in each serve listed.
It's thought that the body can't effectively absorb more than 500mg. Too much and it has to do something with the excess, increasing those risks. So if your diet is not giving you the RDI, splitting dosages over the day with each under 500mg may help.
Vitamin D helps the body to absorb calcium better - they're besties. Many supplements have Vitamin D and Calcium together for that reason. Vitamin K binds to calcium to help ensure it binds to bone.
Q: Do you take a Calcium supplement? Have you checked with your health team the amount you need for your specific lifestyle and health condition? If you haven't, please do. Calcium supplementation is not something to take lightly because of the potential risks. I have osteoporosis so I do supplement and have spoken to my endocrinologist about what I need. The form I take has D3 and K2 in it as well.
Don't take any more calcium than you need - that RDI. It's important to talk to your doctor, a dietitian, your health team about your specific calcium needs - if you should supplement and if so, how much is needed. Understanding how much calcium you take in your diet is a great place to start. There are online tools to help you do that like this one and this one. Have the discussion then make your move.
Vitamin D
We actually make Vitamin D ourselves, synthesised by sunlight on our skin (D3 - cholecalciferol). The catch is that here in Australia, with the highest incidence of skin cancer in the world, we are encouraged to coverup and apply sunscreen. But with that, 31% of us are Vitamin D deficient (Medical Journal of Australia). We can also get Vitamin D in small amounts, from certain foods (plants D2 and animal food sources D3).
Vitamin D supports the absorption of Calcium.
RDI: The Australian Dietary Guidelines says 10.0 µg /day (or about 400IU).
How well we make our Vitamin D is thought to be in our DNA - our genes drive our Vitamin D stores. That's why it's a good idea to ask your health team to test for your Vitamin D levels and get their advice on how much you need to supplement (if any) for your healthy bones.
The amount of sun exposure during the year (taking into consideration to coverup) to get the RDI can be found here on the Healthy Bones Australia website.
It's also quite challenging to get adequate Vitamin D through diet. That's why it's recommended we get our Vitamin D from the sun in the first place and that supplementation may be required.
"Few foods are naturally rich in vitamin D3. The best sources are the flesh of fatty fish and fish liver oils. Smaller amounts are found in egg yolks, cheese, and beef liver. Certain mushrooms contain some vitamin D2; in addition some commercially sold mushrooms contain higher amounts of D2 due to intentionally being exposed to high amounts of ultraviolet light." (The Nutrition Source).
Best bioavailable Vitamin D foods - I couldn't find any information on this. Sorry.
Supplements: "At the supplement counter, you can choose from D3 or D2. Vitamin D2 is ergocalciferol, which differs slightly from D3 but behaves the same way in the body. D3 is slightly more potent.
The main difference between the two supplements is how they are made. D3 comes from animal sources, although it can be made from lichen. D2 is derived from plant sources. If you are a vegan or vegetarian, you'll want to read labels closely." (WebMD)
Vitamin K
Vitamin K is a fat soluble vitamin that comes in 2 forms - phylloquinone and menaquinone. It helps to make various proteins needed for blood clotting and the building of bones.
RDI: The Australian Dietary Guidelines says 60 µg/day (or about 200 IU).
Sources: it's available in some of the foods we eat and It's also made by the bacteria in your gut. Being fat soluble, it's best absorbed when taken/eaten with good fats (like olive oil and avocado).
"The main type is called phylloquinone, found in green leafy vegetables like collard greens, kale, and spinach. The other type, menaquinones, are found in some animal foods and fermented foods. Menaquinones can also be produced by bacteria in the human body. [1]" (The Nutrition Source).
"Vitamin K is broken down very quickly and excreted in urine or stool. Because of this, it rarely reaches toxic levels in the body even with high intakes, as may sometimes occur with other fat-soluble vitamins." (The Nutrition Source)
Supplements: There are 2 types of Vitamin K typically in supplements. MK4 and MK7.
Yet again the research is divided. Some suggesting that Vitamin K is helpful in bone health and others suggesting not. Again, more research needs to be done to establish its effectiveness with more confidence. Talk to your health team about it to see what their view is and what they are basing that on.
Some references have been put in the Read section below for you.
Peptides. Protein. Collagen
Many bone health discussions centre around bone mineral density and that outer hard layer of bone, the cortical bone. But bone is a lot more than its density. Bone strength or quality also comes from the health of the inner trabecular bone area - the scaffolding of our bone.
A lot of that trabecular bone is made up of Collagen. As we age we lose the amount of collagen in our bones, compromising our bone health. "Collagen is the most abundant protein in your body. It accounts for about 30% of your body's total protein." (Cleveland Clinic)
"Because your body naturally produces collagen from amino acids, you can support collagen production by ensuring that you're eating adequate amounts of protein from foods like poultry, fish, beans, and eggs.
In addition to amino acids, your body needs other dietary components for collagen production and maintenance. For example, vitamin C is necessary for collagen synthesis, so having low or deficient levels of vitamin C can lead to impaired collagen production. Consuming plenty of vitamin C-rich foods can help support healthy collagen production. For example, try citrus fruits, peppers, greens, and berries." (Healthline)
Protein is a hot topic right now for women's health because the research suggests we need more of it than we typically consume for optimal health as we age - for muscle and bone health.
RDI: 46 g/day (0.75 g/kg) is what the Australian Dietary Guidelines from 2013 say. Check with your health team for what they recommend and on what basis. Perhaps it's been revised since then. I've seen it as around 1.1-1.3g for every kg of ideal body weight. So if you're 60kg for example, that would be around 66-78g a day. Quite a difference.
Sources: there are both animal and plant sources of protein though animal proteins give you more 'bang for your buck', having to consume less to hit that RDI. It's challenging. That's why protein supplements, collagen supplements are popular.
But...yep...you guessed it...there's currently is not enough clinical research evidence to support the use of collagen supplements for bone health; but its building. To the best of my knowledge and desktop research, the only form of collagen supplement that has undergone the rigors of clinical trials and published results is for a product called Fortibone.
"In conclusion, the findings of this randomized, placebo-controlled trial demonstrate, that supplementation with 5 g of specific collagen peptides significantly increases bone mineral density of the lumbar spine and the femoral neck as well as blood levels of the bone marker, P1NP, in postmenopausal women with age-related decline in BMD." (Specific Collagen Peptides Improve Bone Mineral Density and Bone Markers in Postmenopausal Women—A Randomized Controlled Study )
I take Fortibone for my osteoporotic bones in a product called Whole Body Collagen. I'm not suggesting you do. If you are curious and want to ask your health team about it, go for it. I get it from my naturopath because it's professional use only. I was curious to see if it was listed in the ARTG register and it's not. So I called the company who makes it. It's regarded as a food so that's why it's not listed. However, the key ingredient (ie Fortibone) and its clinical trial information is listed in the Fortibone link above.
Other Trace Minerals
Bones house many trace minerals. Many of which are found in prunes! Important minerals like zinc, magnesium, boron, copper and manganese. This edition is long enough so I won't go into the details here of all those minerals but if you'd like to know more start here and take it from there.
Final Thoughts
Okay. I'm done. That was big. Big from a desktop research point of view and writing process. I hope you've found a few gems. Hit reply and let me know.
Key messages to leave you with:
- Think food first when it comes to your bone health to get the important vitamins and minerals your bones need. Food also contains so many other nutrients that our body needs, beyond bones.
- Supplements are just that - to supplement what you are not taking in from your diet or what you are not able to absorb well. Get advice from your relevant health team members to find out if you need them and how much.
- Measure - Keep a food diary and use the calculators to find out what you are typically consuming in your diet. Ask for relevant blood tests to understand your levels. Then have the informed discussion with your health team members and make your plan - make your moves.
- Your individual needs are just that, yours. Not your mate's and what she takes. Broad RDI's may not be right for you either. Go the next level of detail and get it right for you.
There are so many gaps in research and understanding. This can create much confusion. It's important that current research is on your radar for you to keep an eye on because, as with the RDI's they are 10+ years old. I wonder, are they still right? Time will tell.
Have the conversations with your health team about where they're getting their recommendations from. Back yourself, your intuition and then decide what is right for you.
Remember the contents of this post are meant for education purposes only. This newsletter is here to spark thoughts and conversations not to give advice. Conversation not consultation. I'm not a doctor or a qualified health professional offering advice. That's on you to glean from your health team and determine what's best for you.
Take care, and be kind to you. Because girl...you are just getting started.
Anita xx
p.s. Scroll to look out for other blog posts in my Bone Health Series. They're near by so it won't take long to find them :)
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