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- 1. Chapter 10 Nutrients Involved in Bone Health Lecture and Animation PowerPoint Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. To run the animations you must be in Slideshow View . Use the buttons on the animation to play, pause, and turn audio/text on or off. Please Note : Once you have used any of the animation controls , you must click in the white background before advancing to the next slide.
- 8. Influencing Bone Health: Biological Factors
- 9. Please note that due to differing operating systems, some animations will not appear until the presentation is viewed in Presentation Mode (Slide Show view). You may see blank slides in the “Normal” or “Slide Sorter” views. All animations will appear after viewing in Presentation Mode and playing each animation. Most animations will require the latest version of the Flash Player, which is available at http://get.adobe.com/flashplayer.
- 10. Influencing Bone Health: Modifiable Lifestyle Factors
- 13. Osteoporosis
- 14. Please note that due to differing operating systems, some animations will not appear until the presentation is viewed in Presentation Mode (Slide Show view). You may see blank slides in the “Normal” or “Slide Sorter” views. All animations will appear after viewing in Presentation Mode and playing each animation. Most animations will require the latest version of the Flash Player, which is available at http://get.adobe.com/flashplayer.
- 17. Impact of Poor Bone Health
- 49. Pre-2010 Dietary Intake Guidelines Life Stage (Ages) Infants & Children Men & Women Pregnancy & Lactation Birth – 13 5 mcg (200 IU) 14 – 18 5 mcg (200 IU) 5 mcg (200 IU) 19 – 50 5 mcg (200 IU) 5 mcg (200 IU) 51 – 70 10 mcg (400 IU) 71 + 15 mcg (600 IU)
- 50. 2010 UPDATED Dietary Intake Guidelines NEW RECS: 400 IU (Infants) 600 IU (Adults) 800 IU (70+ years) Life Stage (Ages) Infants & Children Men & Women Pregnancy & Lactation Birth – 12 months 10 mcg (400 IU) 1– 18 yr 15 mcg (600 IU) 15 mcg (600 IU) 19 – 50 yr 15 mcg (600 IU) 15 mcg (600 IU) 51 – 70 yr 15 mcg (600 IU) 71 + yr 20 mcg (800 IU)
Notas del editor
- Figure 10.6
- Kyphosis from page 376
- Figure 10.8
- Figure 10.12
- Figure 10.10
- Page 387 – think there may be a typo/confusing wording in this sentence: High calcium carbonate or citrate supplements can bind the low food phosphorus in the intestine, thus inhibiting its absorption
- Figure 10.14
- Table 10.4
- SLIDE 30: DIETARY INTAKE GUIDELINES This Table contains the Dietary Reference Intakes are the Adequate Intakes (AIs) for Vitamin D (Food and Nutrition Board, Institutes of Medicine, National Academies). Vitamin D is represented in this table as cholecalciferol. The conversion is 1 μg cholecalciferol = 40 IU vitamin D. SCRIPT: 1. In the US, the most current DRIs for Vitamin D were published on January 1, 1997 and remain the current guidelines until further notice. 2. Note that the above DRIs for vitamin D are based on the assumption that the vitamin is not synthesized by exposure to sunlight. 3. Interestingly enough, in the fall of 2008, the Institute of Medicine (IOM) initiated a study to review the Dietary Reference Intakes (DRIs) for vitamin D and calcium, with a report expected for release in the spring of 2010. The review comes as a response to relevant new research on bone health as well as the growing interest in the connection between vitamin D intake and cancer and other chronic disease. 4. Note that the American Academy of Pediatrics has recently updated there guidelines – see next slide
- New vitamin D recommendations By Rob Stein Despite mounting pressure to urge many Americans to sharply boost their vitamin D levels, new official recommendations are not advocating a huge increase in the amount of the "sunshine vitamin" that people get. The United States and Canada asked the Institute of Medicine, which is part of the National Academy of Sciences, to update the official vitamin D recommendations for the first time since 1997. A 14-member expert committee convened for the task concluded that most Americans and Canadians up to age 70 need no more than 600 international units of vitamin D per day. The elderly may need as much as 800, the committee concluded. Previously, experts called for children and younger adults get 200 international units a day, adults ages 50 to 70 get 400 and the elderly to get 600. But a flurry of research indicating that vitamin D may have a dizzying array of health benefits, and that many people may have insufficient levels , had reignited an intense debate over whether federal guidelines were outdated, leaving millions unnecessarily vulnerable to heart disease, cancer, diabetes, the flu and other ailments. Some doctors have begun routinely testing their patients' vitamin D levels and recommending that people should routinely consume 2,000 or 3,000 international units a day. Sales of vitamin D supplements have increased sharply in recent years. Vitamin D may no longer be called the sunshine vitamin. (Jupiter Images) After reviewing nearly 1,000 published studies along with testimony from scientists and others, the expert committee concluded that vitamin D and calcium play an important role in creating and maintaining strong bones. But the committee concluded that while further research was warranted into vitamin D's role in other health issues, at this point the evidence is mixed and inconclusive. The committee noted that other nutrients, such as vitamin E, were thought to have a host of health benefits, an idea which was later disproved and in some cases found to be dangerous. So the committee recommended that 600 international units a day met the need for almost everyone in the United States and Canada, though people age 71 and older may need as much as 800. The committee also concluded that available evidence does not indicate there are widespread deficiencies, as some have suggested, requiring routine screening. In addition, contrary to what some vitamin D proponents have been urging, the committee did not recommend people increase their sun exposure, citing concerns about skin cancer. Scientists have long known that vitamin D is a vital nutrient that the skin produces when hit by sunlight. The amount varies, depending on where the person lives, skin pigment, age and other factors. With people spending more time indoors and covering up and using sunblock when they do go outside, the amount of vitamin D people create in their bodies has been thought to be falling. But the committee concluded that most people can get sufficient vitamin D from their diets or by taking vitamin D supplements. Milk and other foods are fortified with vitamin D and it occurs naturally in others, such as fatty fish. The recommendations disappointed many proponents of higher vitamin D intakes. Michael Holick of Boston University, one of the leading proponents of the supposed benefits of vitamin D, said he was pleased that the committee recommended higher levels than the previous guidelines. But Holick and others argue that there is more than enough evidence to support taking much more on a routine basis to reduce the risk for a host of health problems. Holick, for example, says he personally takes 3,000 international units a day and advises his patients to do so as well. Holick noted that the committee increased the upper limit of what was considered a safe level of vitamin D to 4,000 for adults. 2010 11 30 00 01 By Rob Stein | November 30, 2010; 12:01 AM ET http://voices.washingtonpost.com/checkup/2010/11/new_vitamin_d_recommendations.html New vitamin D recommendations: What they mean A new report from the Institute of Medicine is causing people to reconsider the essential nutrient. Here's what the expert panel said, and why it reached its conclusions. December 06, 2010|By Melissa Healy, Times Staff Writer Every once in a while, some unsung nutrient gets rediscovered and, in the course of a few short years, is rendered virtually magical in the eyes of health professionals and consumers. Foods containing the nutrient come into vogue and supplement use soars. Then, seemingly overnight, the spell is broken. Last week, it was vitamin D's turn to fall from grace. The comedown came courtesy of an expert panel convened by the Institute of Medicine, which advises the government on health issues. The panel's exhaustive report concluded that levels of vitamin D are — thank you very much — just fine in virtually all healthy North Americans. That was surprising to the legions of people who believed that high doses of the vitamin could prevent a laundry list of chronic conditions, including type 2 diabetes, cardiovascular disease, depression, certain cancers, preeclampsia and low birth weight. Their faith in vitamin D, derived from a heap of preliminary studies, prompted many to take mega-doses of the nutrient daily. But the expert panel was unconvinced. It noted that the scientific evidence has been mixed. Moreover, it worried about the risk of undesirable side effects, such as kidney stones, that might come with high levels of supplementation. In short, the jury's still out on the benefits of vitamin D beyond its traditional role in promoting the absorption of calcium for healthy bones. To do that job, virtually all healthy people need only 600 international units (IUs) of vitamin D a day — and those older than 70, 800 IUs. More does not make your bones healthier. So, after all the hype and hope surrounding vitamin D, what's a consumer to do now? Here's a look at what the expert panel said, and why it reached its controversial conclusions. How much vitamin D did the experts say is necessary? For most children, teens and adults, a daily dose of 400 international units (IUs) of the vitamin is sufficient, and 600 IUs recommended. Seniors older than 70 should ideally receive 800 IUs of vitamin D a day, the panel determined. For babies less than 1 year old, the panel considered 400 IUs of vitamin D enough. Those levels are somewhat higher than the ones set in 1997, the last time a government panel examined vitamin D intake. But they are far below what many doctors and supplement advocates had been urging. Why weren't they higher? The idea that people could benefit from daily doses as high as 2,000 IUs is based on the belief that vitamin D can reduce the risk of many chronic diseases, including type 2 diabetes, cardiovascular disease, metabolic disturbances, depression and certain cancers. A slew of recent studies have linked low levels of vitamin D to an increased incidence of these health problems. But the expert panel concluded that the studies were not convincing — many, in fact, showed no such connection — so it based its recommendations only on the amount of vitamin D needed to maintain bone health and prevent fractures. Does that mean I should give up my vitamin D supplements? Maintaining a healthy level of vitamin D through diet alone has become much easier since manufacturers began fortifying foods with the nutrient. Fortified foods — including virtually all milk, many brands of orange juice, and some cheeses, yogurts, margarines and breakfast cereals — are now some of the richest dietary sources of vitamin D. High levels exist naturally in fatty fish such as tuna, salmon and mackerel, and it's also present in egg yolks and beef liver. But there are a lot of people who may still need to add a vitamin D pill to their daily diet. For instance, people who follow a vegan diet need to look hard for supplemental sources of Vitamin D, as do those with milk allergies, lactose intolerance, and people who rarely eat fish. "We didn't actually say in the report that supplementation is verboten," said Dr. Glenville Jones, an endocrinologist at the University of Queensland in Canada who was on the expert panel. So I should keep on buying foods fortified with vitamin D? Definitely, says Katherine Tallmadge, a registered nutritionist and spokeswoman for the American Dietetic Assn., which endorsed the panel's report. In fact, the fortification of foods probably contributed significantly to the panel's finding that most North Americans get enough of the nutrient, even as they raised the recommended daily levels. Can't I get some of the vitamin D I need from the sun? Indeed, the sun is a free, plentiful source of vitamin D. When the sun shines on human skin for at least five to 15 minutes, the body produces the nutrient. But with people spending more time indoors and using sunscreen to prevent skin cancer, this source has fallen on hard times. In fact, the panel didn't even factor in vitamin D from sun exposure when it made its recommendations. Does that mean I should lay off the sunscreen? The sun can be a powerful manufacturer of the nutrient: In 15 minutes, a light-skinned person wearing a bathing suit outside in early July will produce 15,000 to 20,000 IUs of Vitamin D. The body stores excess vitamin D in fat, and some research suggests that it is released as needed. But there's debate about how well that happens, so the panel members suggest that daily dosing of vitamin D is a better bet. Besides, even 15 minutes without sunscreen won't fly with dermatologists. They warn that prolonged exposure to ultraviolet light — either from the sun or in a tanning both — elevates a person's risk of developing melanoma, the deadliest form of skin cancer. So, by all means, slather on that sunscreen. Are there any groups of people for whom the need for vitamin D supplementation is likely to be higher? While the Institute's report assumed away the sun as a source of Vitamin D, they acknowledged that "incidental exposure" plays a role in propping up everybody's levels of the nutrient. For the elderly, that added buffer is largely lost. So among healthy people, those older than 70 need to take in more vitamin D. Breast milk is not a source of vitamin D, so breastfed babies — particularly those who are dark-skinned — should be considered candidates for supplementation from the first week of life. Formula is typically fortified with vitamin D. Patients with kidney disease, including those on dialysis, are at particular risk of vitamin D deficiency — although they'll need to be very careful if they already have an elevated risk for kidney stones, as levels that are too high can exacerbate that risk. Some prescription medications, including the anti-seizure drugs Phenobarbital, Dilantin and Tegretol, appear to depress levels of circulating vitamin D, suggesting that some people with epilepsy should consider supplementation. Diuretics called thiazides, which are used to treat high blood pressure and kidney stones, can increase levels of Vitamin D in the bloodstream. I was told I was deficient in vitamin D. Is it true? Vitamin D deficiency has been defined and tested in widely varying ways. Labs tests for the nutrient have used different standards, different methods and sometimes test for different indicators of vitamin D deficiency. So the first things to ask are: Who told you were deficient, and what measure did they use? Physicians and dieticians reading the IOM report's specialized appendices may be reconsidering what constitute sufficiency in the coming months. Is there such a thing as too much vitamin D? The expert panel's comprehensive report is unlikely to lay this question to rest, although its advice was clear: Taking more than 4,000 IUs of vitamin D a day is risky. Too much Vitamin D can cause kidney stones and hypercalcemia, which in turn can lead to headaches, anxiety, depression, fatigue, stomach pain, cardiac arrhythmia, muscle weakness, aches, pains and fractures. Daily doses above 10,000 IUs a day are known to cause tissue and kidney damage, the panel said. In thinking about the safe upper limit that the panel proposed, keep in mind that the experts were looking for the amount needed by healthy people to maintain their bones. Since the panel wasn't convinced that higher levels of vitamin D could prevent or treat other diseases, it had little tolerance for the risks associated with mega-doses. What are the prospects for clearing up this confusion? In coming years, research will begin to clarify both sides of that equation and draw a clearer picture of the risks that kick in at higher levels of supplementation, as well as the conditions that such supplementation can treat or prevent. Harvard University researchers are enrolling 20,000 subjects for a study to compare rates of cancer, heart disease, diabetes, cognitive decline, depression and respiratory diseases in people randomly chosen to receive a daily dose of 2,000 IUs of vitamin D versus other subjects who get a placebo. Ongoing trials in Israel and India will assess how a year's worth of monthly supplementation with 10,000 IUs of vitamin D affects the development of insulin resistance, metabolic syndrome and diabetes in obese women, and with what side effects. A University of Colorado study will compare rates of respiratory infections among elderly nursing home patients taking as much as 4,000 IUs of vitamin D a day compared to those taking a smaller dose of 400 to 1,000 IUs daily.
- Figure 10.7