Calcium and its Co-FactorsWhen it comes to bone health, calcium is the old standby. This is for good reason since calcium’s role in bones is to fortify bone tissue. However, calcium products vary widely, offering differences in dosages of elemental calcium and absorption.
These can be important considerations because variations in the kind of calcium supplement can mean the difference between taking two and eight pills daily, says Michael Mooney, director of science and education for SuperNutrition, Oakland, CA. The form that delivers the most elemental calcium in the least number of tablets is calcium carbonate, which is 40% elemental calcium and can deliver 1,000 mg in two tablets. Calcium citrate, which is 21% elemental calcium, requires four tablets to deliver 1,000 mg and calcium gluconate, which is 9%, requires eight tablets to deliver 1,000 mg (1).
When taken with food, calcium carbonate’s absorption is enhanced, says Mooney, but the maximum absorption for both calcium carbonate and calcium citrate is about 39%, according to studies. Calcium citrate-malate has been shown to have 5–10% better absorption than calcium carbonate, but it only contains 13% elemental calcium, and therefore requires six tablets to deliver 1,000 mg of elemental calcium.
The more pills, the greater the cost, says Mooney. “Supplemental forms of calcium, such as calcium citrate, calcium gluconate and calcium citrate-malate are synthesized using calcium carbonate as the base material,” explains Mooney. “The extra laboratory processing required to synthesize these forms of calcium makes them cost three to 10 times more than calcium carbonate.”
However, age poses another issue with regard to calcium. “Calcium is more soluble in high-pH stomach acid,” explains Steve Holtby, president and CEO, Soft Gel Technologies, Inc., Los Angeles, CA. “As we age, hypochlorhydria (low stomach acid) is common. Some estimates suggest 30% of the population over 60 produces no hydrochloric acid (HCL); all of these people are at risk of osteoporosis.”
So, while calcium carbonate is relatively inexpensive and provides optimal elemental calcium in fewer doses, it is absorbed “through active transport and is dependent on sufficient HCL concentrations in the stomach,” says Holtby. Calcium citrate, on the other hand can be absorbed by both active transport and diffusion, and therefore is not dependent on HCL in the stomach, he explains.
Neil E. Levin, CCN, DANLA, senior education manager for NOW Foods, Bloomingdale, IL, agrees, saying, “[older customers] tend to do better with predigested (preacidified) supplemental forms. These include calcium as citrate, malate, ascorbate or bonded to specific amino acids.”
James J. Scaffidi, DNMc, BSc, CEO and president of Zycal Bioceutical Healthcare Co., Inc., Toms River, NJ describes a product (Tricalcidin-3) that seeks to solve the issue of bioavailability and amount of elemental calcium by combining calcium citrate, calcium ascorbate, calcium carbonate and vitamin D3, which contains 600 mg of elemental calcium.
Another option, says Anthony Thomas, Ph.D., technical support scientific affairs for Jarrow Formulas, Inc., Los Angeles, CA, is bone-derived ossein-hydrocyapatite complex (OHC). This natural source of calcium, he says, has been shown to outperform some other forms of the mineral and “also naturally provides additional mineral components of bone (e.g. phosphorous, magnesium, trace minerals) as well as components of the organic bone matrix (e.g., type I collagen, osteocalcin, bone stimulating growth factors).”
Getting optimal levels of calcium and other nutrients is important, but Erin Stokes, ND, medical director of MegaFood, Derry, NH, points out that the source for acquiring these nutrients is also important. “I suggest ensuring calcium-rich foods such as yogurt, cheese, sardines, kale and almonds are part of your daily diet and then supplementing to reach the recommended daily amount for your gender and age,” says Stokes. “Remember that a supplement is intended to ‘supplement’ gaps in the diet, not provide excessive amounts.”
In this same vein, Levin suggests “an alkaline-forming diet comprised mainly of minimally processed plant food,” to maintain “proper systemic pH to prevent bone erosion and promote bone maintenance and remodeling.”
Too much of a good thing?Excess calcium has been associated with negative cardiovascular health. One 2010 meta-analysis published inBMJfound that in the pooled analysis of 12,000 participants from 11 randomized controlled trials, calcium supplementation was associated with a 30% increase in incidence of myocardial infarction, or a blockage of blood flow to the heart muscle (2). Put simply, “Calcium in the bloodstream is looking for a home,” says Scaffidi. “If it doesn’t find enough bone tissue, it either sticks to the coronary artery or gets excreted through the urinary tract.”
This accumulation of calcium causes calcification of the arteries called atherosclerosis, a leading cause of heart attack death (3). However, it should be noted that studies have not conclusively proven excess calcium is bad for you. TheBMJmeta-analysis found a relationship between calcium supplementation and myocardial infarction. When describing the limitations of the study, the authors stated: “We excluded studies that compared co-administered calcium and vitamin D supplements with placebo” (2). While an updated meta-analysis found that co-administered calcium and vitamin D was associated with a 24% increase in myocardial infarction, research in this area has been generally contradictory (4).
A separate meta-analysis that included randomized controlled studies of calcium supplementation with and without vitamin D, published in the American Journal of Cardiovascular Drugs determined, “In assessing the totality of evidence to date, it appears that calcium intake, either from diet or from supplements, has little or no effect on cardiovascular disease risk” (5).
A 2014 study, which Levin describes as “the most rigorous to date in terms of size and control of relevant variables,” further challenges the possible relationship between calcium intake and cardiovascular disease risk. Published inOsteoporosis International, it was a long-term prospective cohort study of supplemental calcium use and incident cardiovascular disease in 74,245 women over 24 years, assessing calcium supplement intake every four years (6). “In our long-term prospective study of women, calcium supplement intake was not associated with increased risk of cardiovascular disease,” say the authors. “Rather, we observed an inverse association between calcium supplement use and coronary heart disease.”
Whether or not excess calcium is detrimental to one’s cardiovascular health, the fact remains that calcium works best when consumed in concert with other nutrients. “In my opinion, there is too much focus on calcium for bone health,” says Cheryl Myers, chief of education and scientific affairs at EuroPharma, Inc., Green Bay, WI. “Yes, it is an essential building block, but some countries with very low calcium consumption have better average levels of bone density than people in the United States.” Why this is the case is hard to say but two strong possibilities, says Myers, are that they either have less exposure to things that cause bone loss and have richer sources of other vitamins and minerals more crucial to bone density than calcium alone.“If it doesn’t find enough bone tissue, calcium either sticks to the coronary artery or gets excreted through the urinary tract.” — James J. Scaffidi, DNMc, BSc
“Naturally, nutrient imbalances can be caused by relying on a single nutrient, rather than looking at the range of nutrients needed by the body,” says Levin.
Trace minerals.“Calcium needs magnesium, which needs phosphorous, which need manganese, which needs iron, copper, silver, it goes on and on,” explains Clint DeWitt, co-founder of Coral LLC, Carson City, NV (7). For this reason, he recommends a whole food natural mineral complex, particularly one derived from above-sea coral, which is a natural source of calcium and 73 other trace minerals that are similar in composition to those in our bodies. “It is truly amazing how close the minerals in the sea compare with the minerals in one’s body and bones,” says DeWitt.
Magnesium.“Magnesium is essential for the absorption and metabolism of calcium and the conversion of vitamin D into its active form,” explains Mooney. Structurally, calcium in the bones gives them their hardness while magnesium is found primarily the body’s soft structures, in this case, the bone matrix (8). The bone matrix, containing protein and magnesium, provides the bone with its flexibility and resistance to brittleness (8).
Although the proper balance of calcium and magnesium is an important consideration for heart health, it also translates to bones. Holtby cites a 1995 research study published inNutrition Reviewthat found “magnesium supplementation increases bone density up to 8% on its own and up to 11% when combined with calcium and cofactors such as vitamin D, vitamin B complex, zinc, copper, manganese, silica and boron” (9).
Magnesium is also known to support osteoblast formation (10). Healthy bones require two coordinating actions of bone formation and reabsorption. Formation is accomplished by cells called osteoblasts, and reabsorption by cells called osteoclasts (11). Magnesium deficiency not only reduces bone formation from a lack of osteoblasts, but has also been shown to increase the secretion of pro-inflammatory cytokines that are implicated in increasing osteoclast reabsorption (10).
Vitamin D.While calcium is an important nutrient for maintaining bone health, it doesn’t do as well without vitamin D. “Vitamin D acts like a hormone in the body and helps the body increase absorption of calcium and other minerals,” says Holtby.
Mooney explains that in people with a deficiency, adequate vitamin D status can increase calcium absorption as much as 65%. Unfortunately, 77% of Americans are deficient in vitamin D, meaning that their calcium isn’t where it needs to be: the bones.
A recently published meta-analysis that evaluated randomized controlled studies of calcium plus vitamin D supplementation and fracture prevention found that supplementation with both “produced a statistically significant 15% reduced risk of total fractures and a 30% reduced risk of hip fractures” (12). The authors go on to state that “vitamin D promotes calcium absorption in the gut and helps to maintain adequate serum calcium concentrations to enable normal mineralization of the bone,” and “is needed for bone growth and bone remodeling by osteoblasts and osteoclasts.”
Vitamin K2.Vitamin K2 (as menaquinone-7) is making an appearance in increasingly more products on your shelves. This is for good reason. Eric Anderson, senior vice president global sales and marketing for NattoPharma USA, Metuchen, NJ, describes vitamin K2 as a chaperone. “Unchaperoned calcium, over time, creates a cement-like structure in the arteries, causing them not only to lose the necessary flexibility, but also to create a blockage,” says Anderson. However, with vitamin K2 in the picture, calcium is guided to where it is needed.
Vitamin K2 does this by activating specific proteins, explains Anderson. One such protein, called osteocalcin, directs calcium to the bone mineral matrix and another called matrix Gla protein inhibits calcium from depositing in the arteries and blood vessels upon activation.
In a 2013 study published in Osteoporosis International, 244 healthy postmenopausal women were either given placebo or 180 mcg of vitamin K2 (MenaQ7) for three years (13). During this time, bone mineral density in subject’s lumbar spine, total hip and femoral neck were measured by DXA each year. Results showed that supplementation significantly increased vitamin K status and decreased the age-relation decline of bone mineral content and density in lumbar spine and femoral neck, as well as favorably affecting bone strength.
Like many other nutrients, vitamin K deficiency is prevalent. One study published in Food & Function found that children and adults over 40 were more likely to be deficient in vitamin K (14). The researchers measured this by determining the level of inactive osteocalcin and matrix Gla protein in healthy volunteers. Remember, vitamin K2 activates these proteins, therefore, the more inactive proteins, the less vitamin K2. Children had 8-10 times more inactive osteocalcin than adults. Because activated osteocalcin guides calcium to the bones, this deficiency in vitamin K2 is bone specific, placing them at risk of having weak bones.
It therefore makes sense that vitamin K2 is being tested for use in fortified food such as yogurt. One study published in the Journal of Nutritional Science tested the effects of yogurt fortified with 28 mcg of vitamin K2 menaquinone-7 (as MenaQ7), as well as omega-3 polyunsaturated fatty acids, vitamin D, vitamin C, calcium and magnesium (15). Healthy men and postmenopausal women with a mean age of 56 were either given basic or fortified yogurt twice per day for 12 weeks. After those 12 weeks, levels of inactive osteocalcin and matrix Gla protein in the experimental group decreased by 33% and 24%, respectively, thus improving the vitamin K status in subjects.
“We feel these studies are important as they show vitamin K2 can be accessible to an even larger population, particularly children,” says Anderson. “Getting vitamin K2 from one’s diet is ideal, be it cheese, natto or enriched yogurts, however, as most Western populations are deficient in this essential nutrient, they are not getting enough from their diet, making supplementation a viable alternative.”
Interestingly, vitamin K2 is dependent on vitamin D as well as vitamin A. “The three nutrients together create and activate two proteins guides that tell calcium to away from soft tissues and incorporate properly into bones and teeth,” says Mooney. These “protein guides” are osteoclastin and matrix Gla protein, mentioned previously. Vitamin K2 can’t activate them if vitamin D and A can’t create them. According to the U.S. Department of Agriculture, explains Mooney, 54% of Americans are deficient in vitamin A (retinol, that is, not beta carotene).
Vitamin C.This nutrient is certainly on many people’s radar, though perhaps not for bone health. “Few people understand that all bone is built on a scaffolding of collagen, which absolutely relies on vitamin C for its strength, maintenance and repair,” says Rafael Avila, director of research and development at Nature’s Plus, Melville, NY. “Without sufficient vitamin C, collagen wears down and goes unrepaired, hobbling mineral deposition on the resulting weak collagen scaffolding.”
Mooney seconds the importance of vitamin C, adding that its influence on collagen helps bones maintain the flexibility to absorb impact without fracturing.
Protein complex.Most important, says Scaffidi, is having sufficient bone tissue for minerals to stick to. That is why he recommends a product by Zycal Bioceuticals Healthcare Co. whose active ingredient (Cyplexinol), a protein complex, Scaffidi says activates stem cells to stimulate the growth of bone tissue. “Now we have a surface for your minerals,” he says.
In a 2013 case study published inIntegrative Medicine, a 59-year-old female with menopause-associated osteoporosis saw a 51.5% increase in bone mineral density after 34 months of consuming Zycal’s proprietary protein complex (16).
HerbsAndrographis.Annie Eng, CEO of HP Ingredients, Brandenton, FL, says that bone health is also subject to inflammatory response. “The NF-kappaB pathway has been implicated to an extent in accelerating bone degradation,” says Eng. “NF-kappaB activation is essential for Receptor Activator for NF-kappaB ligand (RANKL)-induced osteoclast formation.” Discussed previously with regard to magnesium, healthy bones require two coordinating actions of bone formation and reabsorption accomplished by osteoblasts and osteoclasts, respectively.
However, like most things, age causes some unwanted changes. This means excessive bone reabsorption by osteoclasts without adequate formation by osteoblasts, which causes osteoporosis (12). In the face of excess osteoclast activity, RANKL-induced osteoclast formation further exacerbates the problem. The patented andrographolide in HP Ingredient’s ParActin is a natural NF-kappaB inhibitor that “significantly decreases osteoclast formation in the bone marrow via suppression of RANKL.”
In one study published in theInternational Journal of Molecular Sciences, mice with bones that mimic those of postmenopausal women with osteoarthritis were treated with andrographolide. Results showed a significant increase in bone mass (11).
As Avila points out, andrographolide is also a strong antioxidant. Antioxidants target free radicals that can attack a variety of tissues and systems. “Andrographolide phytonutrients are particularly effective at the removal of superoxide free radicals from water-soluble microenvironments (i.e., bone tissue),” says Avila. “The andrographolides essentially get rid of the free radicals that make bone mineral deposition more difficult and bone removal more easy.”
Horsetail.“This herb is known to many as silica or equisetum arvense and has a long history of supporting joints and bones, maintaining healthy hair, skin and nails, and promoting collagen production,” says Judy Haswell, president and CEO of Alta Health Products, Idaho City, ID.
This plant-based natural source of silica is beneficial for collagen production and bone building, says Myers, and rather popular in other parts of the world. “In France, the top products in pharmacies for bone support are silica-based, not calcium-based,” says Myers.
However, extracts must be purified, explains Myers, because the herb contains harsh crystals and an enzyme called thiaminase that can deplete B vitamins. “The form of silica in our product [Bone-Sil] boosts calcium absorption into the bone by 50% and creates a collagen matrix in the bone to better hold onto mineral deposits,” she says.
Research shows that horsetail may have a similar effect on bones as andrographis. A 2012 study published in Cell Proliferation found, “In osteoclast precursors committed to osteoclastogenesis, E. arvense caused dose-dependent inhibitory effect” in cell cultures (17).
Individual NeedsCustomers have a lot of options for supporting bone health, and rightfully so. “Knowledgeable nutritionists and healthcare experts have long held the view that the unique health characteristics and dietary needs of each individual determine which form of any essential nutrient is best,” says Avila. There is no one-size-fits-all approach. Therefore, there are a variety of factors to consider when helping customers pick the right product.
According to the National Osteoporosis Foundation, one in two women and one in four men over the age of 50 will break a bone due to osteoporosis. So, although women are at a greater risk of developing the disease, both men and women suffer from it and should consider supporting bone health a priority, especially from a younger age.
“It is estimated that girls reach their peak bone mass as early as age 18, while boys attain their peak bone mass at age 20,” says Holtby. “After this age one can expect a slow and steady decline.” So, women get a head start on men with regard to this decline, and are particularly vulnerable post-menopause, but both genders’ risk increases with age.
Interestingly, while there is greater prevalence in women, “men with hip fractures suffer much higher rates of mortality than women; twice as high in the first six months after the injury,” says Levin. Therefore, negligence of one’s bone health in men is just as dangerous, if not more dangerous as that of women.
Not all men and women are created equal either, as there are individual factors to consider such as health conditions, age and family history. A health professional such as a nutritionist will be better equipped to guide someone in what nutrients and at what amount works best for them. “The imperative of calcium absorption and deposition for a 55-year-old woman who never ate well is far greater than that of a 30-year old who always ate healthful, nutritious foods, high in essential minerals,” says Avila.WF
Select Bone Health Products: Alta Health Products: Herbal Organic Silica with Bioflavonoids.
Coral LLC: Coral Complex3, Coral EcoPure, Coral Daily D3, Coral CalMag, Coral CellEnergy H2, Coral Chewables, Alkalizing Water Treatment, Coral Joint & Collagen Support.
EuroPharma: OsteoStrong, Vitamin D3 Chewable, Strontium, Bone-Sil.
HP Ingredients: ParActin.
Jarrow Formulas: Bone-Up, Ultra Bone-Up, Bone-Up Three-Per-Day, Bone-Up Vegetarian.
MegaFood: MegaFood Multi for Healthy Bone.
NattoPharma USA: MenaQ7.
Nature’s Plus: Animal Parade Calcium Children’s Chewable - Vanilla Sundae Flavor, Animal Parade Sugar Free Calcium Children’s Chewable - Vanilla Sundae Flavor, Animal Parade Sugar Free Vitamin D3 500 IU Children’s Chewable - Black Cherry Flavor, Animal Parade Vitamin D3 200 IU Liquid Drops - Orange Flavor, Animal Parade Vitamin D3 500 IU Children’s Chewable - Black Cherry Flavor, AgeLoss Bone Support Extended Release Tablets, Activated Coral Calcium Vcaps, Bone Power - Calcium with Boron – Softgels, Cal/Mag 500/250 mg Tablets, Cal/Mag Citrate Vcaps, Cal/Mag Vcaps 500/250 mg, Cal/Mag/Vit D3 with Vitamin K2 Chewables – Chocolate, Cal/Mag/Vit D3 with Vitamin K2 Chewables – Vanilla, Cal/Mag/Vit D3 with Vitamin K2 Tablets, Cal/Mag/Zinc 1,000/500/75 mg Tablets, Calcitron 2:1 Ratio Mag./Calc. Tablets, Calcium 600 mg Tablets, DYNO-MINS line, Liquilicious Liquid Calcium - Malted Milk Flavor, Nutri-Cal Hearts Chewables, Source of Life Cal/Mag 500/250 mg Tablets, Source of Life Garden Calcium Vegan Capsules w/AlgaeCal (Organic), Source of Life Garden Bone Support Vegan Capsules w/AlgaeCal (Organic), Source of Life Garden Vitamin D3 5000 IU Vegan Capsules (Organic), Source of Life Garden Vitamin K2 120 mcg Vegan Capsules (Organic).
NOW Foods: Calcium/ Magnesium with Vitamin D-3 and Zinc, Calcium Citrate, Magnesium & Calcium, Full Spectrum Minerals, Red Mineral Algae, Vitamin D-3 5,000 IU, MK-7/ Vitamin K-2 , Citrate Powder.
Soft Gel Technologies, Inc.: Vitamin D3 in soft gelatin capsules—400 IU, 1000 IU and 5000 IU.
SuperNutrition: SuperNutrition Calcium Blend, Women’s Blend, Menopause Multiple, Opti-Energy Pack, PreNatal Blend and SuperImmune Multivitamin.
Zycal Bioceuticals Healthcare Co.: Ostinol Standard 150, Ostinol Standard 350, Ostinol Standard 450, Ostinol Standard 700, Ostinol Standard 900, Tricalcidin-3 Extra Strength, Pro-stiminol Standard 150, Pro-stiminol Standard 350, Pro-stiminol Standard 450, Pro-stiminol Standard 700, Pro-stiminol Standard 900
References
- C.M. Weaver, R.P. Heaney. “Calcium in Human Health (Nutrition and Health).” Humana Press. 2007
- M.J. Bolland, et al. “Effect of calcium supplementation on risk of myocardial infarction and cardiovascular events: meta-analysis.” BMJ. 2010.
- “High Calcium - Low Magnesium Risk.” http://www.nutritionalmagnesium.org/high-calcium-low-magnesium-risks/. Accessed May 23, 2016.
- M.J. Bolland, et al. “Calcium supplements with or without vitamin D and risk of cardiovascular events: reanalysis of the Women’s Health Initiative limited access dataset and meta-analysis.” BMJ. 2011.
- L. Wang, et al. “Calcium Intake and Risk of Cardiovascular Disease: A Review of Prospective Studies and Randomized Clinical Trials.” Am J Cardiovasc Drugs. 12(2): 105–116. 2012.
- J.M. Paik, et al. “Calcium Supplement Intake and Risk of Cardiovascular Disease in Women.” Osteoporos Int. 25(8): 2047-2056. 2014.
- “Why We Need Calcium.” https://coralcalcium.com/why-we-need-calcium.php/. Accessed 5/24/2016.
- M.S. Seelig, A. Rosanoff. “The Magnesium Factor.” Avery. New York. 2003.
- J.E. Sojka, C.M. Weaver. “Magnesium supplementation and osteoporosis.” Nutrition Review. 53(3):71-74. 1995.
- J.H.F. de Baaij, et al. “Magnesium in Man: Implications for Health and Disease.” Physiological Reviews. 95(1): 1-46. 2015.
- 12. “Paractin: Scientific Breakthroughs for Bone, Joint and Muscle Health.” WholeFoods Magazine.
- C.M. Weaver, et al. “Calcium plus vitamin D supplementation and risk of fractures: an updated meta-analysis from the National Osteoporosis Foundation.” Osteoporos Int. 27(1):367-376. 2016.
- M.H. Knapen, et al. “Three-year low-dose menaquinone-7 supplementation helps decrease bone loss in healthy postmenopausal women.” Osteoporos Int. 24(9):2499-2507. 2013.
- E. Theuwissen, et al. “Vitamin K status in healthy volunteers.” Food Funct. 5(2):229-234. 2014.
- H.J. Marjo, et al. “Yogurt drink fortified with menaquinone-7 improves vitamin K in a healthy population.” Journal of Nutritional Science. 4(35). 2014.
- D. Tripodi. “ The Osteoinductive Effects of Cyplexinol in the Effective Management of Osteoporosis: A Case Study.” Integrative Medicine. 2013.
- J. Costa-Rodrigues, et al. “ Inhibition of human in vitro osteoclastogenesis by Equisetum arvense.” Cell Prolif.
