by Marion Nestle

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Feb 26 2013

Supplements? Advice about Calcium and Vitamin D vs. Osteoporosis

Malden Nesheim and I wrote an editorial for the Annals of Internal Medicine that has just gone online, and is likely to elicit plenty of discussion.  We comment on the highly conservative, evidence-based recommendations of the U.S. Preventive Services Task Force for taking supplements of calcium and vitamin D as a means to prevent osteoporosis.

Our commentary: “To Supplement or Not to Supplement: U.S. Preventive Services Task Force Recommendations on Calcium and Vitamin D.”  Here’s what we said:

In this issue, the U.S. Preventive Services Task Force (USPSTF) plunges headlong into ongoing debates about whether healthy adults—those who show no signs of vitamin D deficiency or osteoporosis—should be advised to take combined supplements of calcium and vitamin D to prevent bone fractures and, if so, at what level (1).

In terse statements unlikely to settle the debates, the Task Force states first that insufficient evidence makes it impossible to determine how supplementation affects fracture incidence in men or premenopausal women. Next, it deals with postmenopausal women. For this group, the Task Force says that evidence is insufficient to assess the effects of daily supplementation with greater than 400 IU of vitamin D3 and greater than 1000 mg of calcium. The Task Force’s unambiguous conclusion: Supplementation at or below those levels does not prevent fractures. Because supplementation at or below 400 IU of vitamin D3 and 1000 mg of calcium seems to convey a slightly increased risk for renal stones, the USPSTF recommendation for postmenopausal women is also unambiguous: “do not supplement.”

The Task Force based these decisions on 2 commissioned evidence reviews and a meta-analysis  (2 - 4). More recent data from the Women’s Health Initiative also are consistent with inconclusive findings, except among a subgroup of long-adherent supplement recipients who experienced a reduced risk for hip—but not total—fractures (5).

The Task Force’s recommendations must be interpreted in the light of ongoing disputes about the most effective method for assessing vitamin D deficiency, whether calcium and vitamin D supplements are needed by a large portion of the population, and what level of supplementation might best maximize benefits and minimize risks.

In 2011, after reviewing more than 1000 studies, the Institute of Medicine (IOM) concluded that vitamin D and calcium are indeed critical to bone health but their role in other diseases—cancer, heart disease, diabetes, immune function, and reproductive health, for example—remains uncertain. The IOM did not consider deficiencies of either calcium or vitamin D to be serious problems in the United States, except among certain population groups. Instead, because of widespread fortification and supplementation, the IOM was concerned about the possibility of adverse consequences from oversupplementation (6).

With risks as well as benefits in mind, the IOM established the average adult daily requirement for calcium at 800 to 1000 mg depending on age, the Recommended Dietary Allowance (the amount needed to meet the needs of about 97% of the population) at 1000 to 1200 mg, and the safe upper level of intake at 2000 to 2500 mg. Its corresponding recommendations for vitamin D were 400 IU, 600 IU (800 IU for older adults), and 4000 IU, respectively. The IOM viewed these levels as sufficient to maintain blood levels of 25-hydroxyvitamin D at or above 20 ng/mL, a level it considered adequate to meet population-based needs regardless of amounts synthesized as a result of sun exposure.

Vitamin D, of course, is not a vitamin in the usual sense. It is a hormone produced in response to the action of sunlight on skin. Like other hormones, vitamin D has multiple roles in the body, not all of them well-understood. Vitamin D supplementation, therefore, must be considered a form of hormone replacement therapy. As such, it raises all of the questions about efficacy, dose, and side effects currently asked of such therapies.

In that light, the 2011 recommendations of the Endocrine Society deserve special scrutiny (7). The Society approaches questions about vitamin D from a standpoint quite different from that of the IOM. It appointed its own task force to make recommendations based on the premise that vitamin D deficiencies are common among all age groups. The Society prefers 30 ng/mL of 25-hydroxyvitamin D as the target level for maximum benefits. By that criterion, virtually all U.S., Canadian, and European adults are deficient in hormone vitamin D and require daily supplements of 1500 to 2000 IU. For adults with demonstrated deficiency, the Society recommends treatment with 50 000 IU of the hormone once a week or daily supplementation of 6000 IU for 8 weeks, followed by 1500 to 2000 IU for maintenance.

This clinical endocrinology perspective differs from the nutrition science perspective of the IOM committee, whose members tend to interpret studies of single nutrients within the context of the diet as a whole. From this standpoint, the amount of hormone generated by the action of sunlight on skin (which ought to be more than adequate for people who spend time outdoors in latitudes as far north as Boston) is crucial to decisions about supplementation. The IOM and Endocrine Society debated their conflicting perspectives in an exchange published in 2012 (8 - 9). The insufficiency of research to resolve such arguments has permitted vitamin D to become “trendy.” It is advertised on boxes of fortified cereals, has its own prosupplement advocacy group, and generates millions in annual supplement sales (10).

The USPSTF’s recommendations can be understood as an attempt to clarify the present situation with respect to one specific outcome of supplementation. In doing so, its recommendations have a substantial advantage. They depend on hard end points—fractures—rather than on blood levels of 25-hydroxyvitamin D, at best an indirect measure of vitamin D adequacy. The USPSTF uses the same precautionary approach as did the IOM. In the absence of compelling evidence for benefit, taking supplements is not worth any risk, however small.

A previous attempt to sort through the various claims for vitamin D noted an urgent need for further research to answer fundamental questions about the risks and benefits of sun exposure, fortification, and supplements, and the hormone’s role in body functions beyond bone mineralization (11). The USPSTF plans to publish further recommendations on the role of vitamin D in cancer prevention. When it does, we hope it will keep in mind the value of making a single recommendation about vitamin D and calcium supplementation that will encompass all potential benefits and risks. Multiple recommendations by condition confuse practitioners and the public. While we wait for the results of further research, the USPSTF’s cautious, evidence-based advice should encourage clinicians to think carefully before advising calcium and vitamin D supplementation for healthy individuals.

References

1  Moyer VA; U.S. Preventive Services Task Force.  Vitamin D and calcium supplementation to prevent fractures in adults: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2013. [Epub ahead of print]

2  Cranney A, Horsley T, O’Donnell S, Weiler H, Puil L, Ooi D, et al.  Effectiveness and safety of vitamin D in relation to bone health. Evid Rep Technol Assess (Full Rep). 2007:1-235. [PMID: 18088161]

Chung M, Balk EM, Brendel M, Ip S, Lau J, Lee J, et al.  Vitamin D and calcium: a systematic review of health outcomes. Evid Rep Technol Assess (Full Rep). 2009:1-420. [PMID: 20629479]

Chung M, Lee J, Terasawa T, Lau J, Trikalinos TA.  Vitamin D with or without calcium supplementation for prevention of cancer and fractures: an updated meta-analysis for the U.S. Preventive Services Task Force. Ann Intern Med. 2011;155:827-38. [PMID: 22184690]

Prentice RL, Pettinger MB, Jackson RD, Wactawski-Wende J, Lacroix AZ, Anderson GL, et al.  Health risks and benefits from calcium and vitamin D supplementation: Women’s Health Initiative clinical trial and cohort study. Osteoporos Int. 2013;24:567-80. [PMID: 23208074]

Institute of Medicine.  Dietary Reference Intakes: Calcium, Vitamin D. Washington, DC: National Academies Pr; 2011.

Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, et al; Endocrine Society.  Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011;96:1911-30. [PMID: 21646368]

Rosen CJ, Abrams SA, Aloia JF, Brannon PM, Clinton SK, Durazo-Arvizu RA, et al.  IOM committee members respond to Endocrine Society vitamin D guideline. J Clin Endocrinol Metab. 2012;97:1146-52. [PMID: 22442278]

Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, et al.  Guidelines for preventing and treating vitamin D deficiency and insufficiency revisited. J Clin Endocrinol Metab. 2012;97:1153-8. [PMID: 22442274]

10 Supplements stand out as 2008 sales bright spot for U.S. nutrition industry. Vitamins: D still shines. Nutrition Business Journal. 2009;14(6/7):5. Accessed athttp://newhope360.com/research-and-insights/supplements-stand-out-2008-sales-bright-spot-us-nutrition-industry on 15 February 2013.

11 Brannon PM, Yetley EA, Bailey RL, Picciano MF.  Overview of the conference “Vitamin D and Health in the 21st Century: an Update”. Am J Clin Nutr. 2008;88:483S-490S. [PMID: 18689388]  

Here’s the first objection:

Feb 25 2013

New books on how the food industry hooks us on junk food

Two new books out on the same day, both looking at similar topics but from different angles, both well worth reading.  I did blurbs for both.

Melanie Warner, Pandora’s Lunchbox: How Processed Food Took Over the American Meal, Scribner, 2013.

Pandora's Lunchbox: How Processed Food Took Over the American Meal

Warner used to cover the food business beat for the New York Times.  She knows what she’s talking about.

My blurb:

In Pandora’s Lunchbox, Melanie Warner has produced an engaging account of how today’s “food processing industrial complex” replaced real foods with the inventions of food science.  Her history of how this happened and who benefits from these inventions should be enough to inspire everyone to get back into the kitchen and start cooking.

And here is Warner in the weekend’s Wall Street Journal on the liquification of chicken nuggets (white slime, anyone?).

 

Michael Moss, Salt Sugar Fat: How the Food Giants Hooked Us.  Random House, 2013.

Moss wrote a Pulitzer Prize winning article for the New York Times on failures in our food safety system.  His article based on his new book appeared in Sunday’s New York Times Magazine.

My blurb:

Salt Sugar Fat is a breathtaking feat of reporting.  Michael Moss was able to get executives of the world’s largest food companies to admit that they have only one job—to maximize sales and profits—and to reveal how they deliberately entice customers by stuffing their products with salt, sugar, and fat.  Anyone reading this truly important book will understand why food corporations cannot be trusted to value health over profits and why all of us need to recognize and resist food marketing every time we grocery shop or vote.

And here’s the Wall Street Journal’s review of both (which is what happens when books on the same topic are published on the same day).

Feb 22 2013

Kellogg’s Scooby-Doo: nutritionally groundbreaking?

Can something like this be nutritionally revolutionary?

 

Kellogg has just launched this cereal with just 6 grams of sugars per serving—half of what’s in most other cereals aimed at kids.

It’s also lower in sodium, but everything else about it looks pretty much the same:

http://www.kelloggs.com/content/dam/common/products/nutrition/124171.jpg

Will Kellogg put money behind this cereal and market it with the millions it spends to market Froot Loops?   Will it reduce the sugars in its other cereals?  Will other cereal companies do the same?

Or will Scooby Doo suffer the fate of Post’s no-added-sugar and otherwise unsweetened Alpha Bits introduced in around 2005?

http://www.chewonthatblog.com/wp-content/uploads/2012/09/11alphabits.jpg

Post put no money into marketing the cereal and dropped it after just a few months (Alpha Bits now has 6 grams of sugars per serving).

Let’s give Kellogg some credit for giving this a try.   I’ve looked for Scooby Doo in grocery stores but haven’t been able to find it.

I will watch its fate with great interest.

Update: Thanks to Cara for pointing out that with Scooby Doo, Kellogg adds a cereal to its portfolio that meets requirements of the WIC (USDA’s Women, Infants, and Children’s nutritional support program).  As Jessica, a Kellogg rep explains, “The benefit of this cereal is that it’s WIC eligible and boosts several vitamins and minerals, is low in fat, is a good source of fiber and vitamin D and an excellent source of iron.”

And thanks to an anonymous writer for pointing out that Scooby Doo is directly competing with General Mills’ Dora Explorer cereal for the lucrative WIC market, one that should amount to nearly $7 billion in 2013.  WIC specifies what the benefits can be used to buy.  Cereal companies want to be sure they are in that market.

Feb 21 2013

Grand jury indicts Peanut Corporation of America officials

The wheels of justice really do grind slow, but they sometimes do grind.  A federal grand jury has indicted four officials of the Peanut Butter Corporation of America for “conspiracy, wire fraud, obstruction of justice and others offenses related to contaminated or misbranded food.”

Translation: Salmonella that sickened more than 500 people and killed at least 8.

The documents in the case have just been unsealed:

I’ve been following this particular food safety tragedy for several years now.  The offenses were so egregious—officials blatantly ignored positive tests for Salmonella, for example—that some kind of punishment seemed warranted.

According to the account in USA Today:

The indictment alleges that PCA officials affirmatively lied to their customers about the presence of salmonella in PCA’s products,” said Stuart Delery, principal deputy assistant attorney general.

Delery also said some officials at PCA, no longer in business, fabricated lab results certifying to customers that the products were salmonella free “even when tests showed the presence of salmonella or when no tests had been done at all.”

As lawyer Bill Marler writes,

These indictments will have a far reaching impact on the food industry.  Corporate executives and directors of food safety will need to think hard about the safety of their product when it enters the stream of commerce.  Felony counts like this one are rare, but misdemeanor charges that can include fines AND jail time can and should happen.

Is this a sign that courts might be taking food safety problems more seriously?  If so, it’s about time.

Addition, February 22:  Food Safety News has a handy timeline of the Peanut Corporation events.

Feb 19 2013

The horsemeat scandal–an object lesson in food politics

The unfolding drama around Europe’s horsemeat scandal is a case study in food politics and the politics of cultural identity.

Cultural identity?  They (other people) eat horsemeat.  We don’t.

Most Americans say they won’t eat horsemeat, are appalled by the very idea, and oppose raising horses for food, selling their meat, and slaughtering horses for any reason.

These attitudes have created dilemmas.  Since Congress effectively banned horse slaughter in 2006, roughly 140,000 horses a year have been transported to Canada and Mexico to be killed.  Whether this is better or worse for the horses is arguable.  Some—perhaps most—of that meat will be exported as food.

As Mal Nesheim and I wrote in our book about the pet food industry, Feed Your Pet Right, most—more than 90%—of domestic horsemeat ended up in pet food (the rest was eaten or shipped to Europe).  In the 1920s, horse slaughterhouses started pet food companies as a means to dispose of the meat.  Horsemeat remained a major ingredient of dog foods throughout the 1940s.

Since then, pet food companies replaced horsemeat with meats from other animals.  Although it continues to be permitted in pet food, I’m not aware of any company that would dare use it.  It would have to be disclosed on package labels.

That brings me to the European horsemeat crisis, one brought about by advances in DNA technology that allow officials to test for species in foods.

I’m indebted to Joe O’Toole, president of Lucullus, a French specialty food company, for keeping me up to date on the unfolding saga of how horsemeat got into European hamburger and so many other foods.  He sent me links to early stories:

The problem first emerged earlier in January when the Food Safety Authority of Ireland handed over results of DNA tests it had carried out on burgers produced in Ireland for sale in the UK. Samples from 10 of 27 products sourced from three processing plants had tested positive for horse DNA. One sample is said to have contained 29 percent horse.

As the article explained, the immediate response was “a relatively faultless exercise in damage control.”  Food processors immediately recalled their products and Tesco, Britain’s largest supermarket chain, placed an ad and followed it up with a video apology.  This is viewed as excellent damage control.  Although Tesco shares dropped by 1 percent for a loss of  $475 million, it could have been worse.  

Leaving aside the cultural prohibitions against eating horsemeat, here’s what I find fascinating:

  • DNA technology made this possible.
  • The supply chain is so complicated and involves so many countries—Romania, Ireland, Netherlands, Spain, Poland, France, and, no doubt, others—that where the meat comes from is impossible to trace.
  • The finger pointing  over who is to blame.
  • The enormous number of companies involved.
  • The idea that this is a drug issue (horses are treated with drugs).
  • The idea that horse transport is used as a cover for smuggling (drugs and people).
  • The involvement of organized crime (if selling horsemeat is illegal…).

By far the best place to start on this story is Felicity Lawrence’s Horsemeat Scandal: The Essential Guide, in The Guardian. She did this as a Q and A:

1. Where did the horsemeat scandal begin?

2. Where did the horse and pig found by the Irish in beef products come from?

3. Why did some products contain so much more horse than others?

4. How did the rest of Europe get involved?

5. Is the source of the Irish horsemeat the same as the French one?

6. Why are the supply chains so complex?

7. Why has it happened?

8. How is the meat industry regulated?

9. What about industry claims that it has full traceability?

10. What happened to government control of food safety and standards?

11. Where do the horses come from?

12. What part do UK horse abattoirs play?

13. Why are governments talking about organised crime?

14. Is it a health problem?

I will have more to say about this later, as more details emerge.  Stay tuned!

Addition, February 27: Australia Food Safety News offers this terrific infographic on the scandal.

Feb 15 2013

A gift from AGree: position papers on food and agriculture.

AGree is a foundation-sponsored group devoted to nonpartisan ways to “transform federal food and agriculture policy to meet the challenges of the future:”  future demands for food and improvements in conservation, public health, and agricultural communities.   

It has just posted a series of position papers reflecting its members’ short- and long-term thinking about how to:

AGree also offers a report on Facing the Future: Critical Challenges to Food and Agriculture.  It has identified a set of strategies in addition to the ones listed above to address the challenges confronting the global food and agriculture system.

 

These papers are useful for anyone interested in how to improve agricultural systems and it’s great that this group is laying the groundwork for serious thinking about these issues.

Feb 11 2013

My small share of Ed Koch’s legacy: an apartment in New York

Among the many articles about former New York City Mayor Ed Koch, who died on February 1, almost all mentioned his rent-controlled apartment in Greenwich Village.   Few noted that NYU owned its building.

Several readers of this blog, knowing that I have lived in that apartment since Koch moved out, suggested I say a word  about it.  This is not the first time I’ve been asked.  I told some of the story to the New York Times in 2002.

As the Times reported last week,

In 1967, he [Koch] moved to a one-bedroom unit at 14 Washington Place. This was the rent-controlled apartment that he originally considered more appealing than Gracie Mansion. It had a working fireplace and the occasional rodent visitor — though no cockroaches. And besides, he told a reporter, “I know where everything is.”

“It’s small. I like it. It’s me,” he said, just before assuming office. “I don’t care what anybody says: I won’t give it up.”

I arrived in New York in the fall of 1988 when I joined the NYU faculty as chair of what was then called the Department of Home Economics and Nutrition (now the Department of Nutrition, Food Studies, and Public Health).

NYU rents housing to some of its faculty, and assigned me to a small, one-bedroom apartment in what used to be the maid’s quarters at the back of one of the university’s town houses on Washington Square.  The apartment had no kitchen.  The refrigerator in the living room.  When I complained, they insisted this was an improvement; the previous tenant kept it in her bedroom.

I was new to New York real estate, and longed for something more appropriate for someone who cares about food.

I got my chance a year later when Ann Marcus became dean of my school.  She arranged for me to meet the head of NYU’s  housing office to discuss options.  I missed California and wanted a garden.  Well, he said, it’s too bad about the Koch apartment.  It has a large terrace—but Koch will never move.

That surprised me.  I had just read that Koch, who had just lost the primary election to David Dinkins, was negotiating for an apartment at 2 Fifth Avenue.  His sister Pat worked at NYU.   I went straight to her and explained that this was about an apartment in New York.  Was her brother really leaving?  “He’s packing this weekend,” she told me, “go take a look.”

I did and found the Mayor on the telephone surrounded by bodyguards.

They said “Do you have any idea how lucky you are?  His new apartment may be bigger, but this one is nicer.”

Really?  This seemed like a stretch.  Every inch was covered with furniture and the closets were so full that stuff fell out of them when I opened the doors.  Yards of dark green paint were hanging off the ceilings.  The window shades were drawn—security—and the place was dark.

But the terrace!

By the time I moved in three months later, NYU had done a renovation.  The walls shone with white paint.   The galley kitchen had been converted to a pass-through. The fireplace worked.  The terrace had new tiles.  I could see the Empire State Building from the living room window.  It would do just fine.

I still had to cope with the bullet-proof windows that hardly opened, the heavy security doors, and the secure telephone lines that cost $300 to replace.  And the rent was a lot more than Koch’s $475.

That was 1990.  I’ve now lived in the apartment as long as Koch did.   I’m still grateful to him for leaving at just the right time.

I feel the same way about the apartment that he did:

It’s small. I like it. It’s me. I won’t give it up.

Feb 8 2013

Rumor: the White House is holding out for weak calorie labeling

I hope the rumors I’m hearing are not true.

What sources are telling me is that the White House has decided not to allow the FDA to require calorie labels in movie theaters or anywhere else where selling food is not the primary business.

If these rumors have any validity, this situation is a sad commentary on how corporate pressures are undermining Michelle Obama’s Let Move campaign.

There is no practical reason that keeps movie theaters from posting calorie labels.

Plenty are already doing it.  New York City has had calorie labeling in movie theaters since 2008.  And guess what?  The world has not come to an end.

It’s approaching three years since President Obama signed the Affordable Care Act, which authorizes national calorie labeling.

But the FDA still has not issued final rules, reportedly because the White House is holding them up.

The delay has left plenty of time for industry lobbying and pushback.

If the new rules exempt movie theaters and other such places, New York will not be able to continue requiring them to post the information.  That would be a significant setback.

So would exempting prepared foods in chain groceries and convenience stores, as the Center for Science in the Public Interest makes clear.

If you have concerns about this issue, send a message to Mrs. Obama at the White House.

Menu labeling that covers movie theaters as well as fast-food places will help people make healthier food choices.  It will also be a significant achievement of Let’s Move.

In the meantime, I’m keeping fingers crossed that the rumors are false.

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