Calcium, Vitamin D, and Osteoporosis

The importance of lifestyle choices

and reasons to avoid calcium supplements
by Miles Hassell MD
for everyone, the decision to exercise daily is
This handout is a supplement to Good Food, Great especially vital for someone who already has
Medicine (3rd edition), a Mediterranean diet and osteoporosis. I strongly recommend a daily
lifestyle guide and cookbook. The book is a exercise program that involves both weight bearing
practical, easy-to-read resource offering both the and muscle building components, and encourage
evidence and the tools to help prevent or reverse those who are able to also include 2 minutes of
heart disease and type 2 diabetes, control high “hopping”.2 A physical therapist can design a
blood pressure, improve cholesterol levels, reduce program to follow at home to improve bone
risk of stroke, dementia, and cancer, and lose strength, and reduce fracture risk, as well.
weight without deprivation. Good Food, Great
Medicine presents simple food and lifestyle choices Get calcium from whole foods,
to reduce medications and improve your long term
health. (For more principles to eat by, see Fat Is
not calcium supplements
Good, Bagels Are Bad on the resources tab at Calcium is important for bone health, but 800-
goodfoodgreatmedicine.com) 1,200 mg a day from food sources appears to be
plenty. In contrast to naturally occurring calcium
found in whole foods, there is substantial (and
The prevention and management of osteoporosis
growing) evidence that calcium from supplements
and osteopenia has many facets. This handout
may actually be harmful. I do not recommend
addresses those lifestyle choices which seem to be
calcium supplements for anybody. Adequate
the most effective in achieving the primary goal of
calcium from food sources is easily achieved if you
preventing fractures (broken bones) and improving
include two or three servings of calcium-rich foods
bone strength and resilience.
daily (see box on page 2). Avoid calcium-fortified
We will explore the following lifestyle choices: foods like juice and commercial breakfast cereal in
§ Exercise favor of naturally occurring calcium in whole foods.
§ Calcium and calcium supplements Calcium-fortified foods are just another form of
§ Whole foods to support bone health calcium supplement.
§ Vitamins D, B12, and K
§ Mediterranean diet and strong bones Why I don’t recommend supplemental
§ A few bone-friendly recipe ideas
calcium or calcium-fortified foods
§ Most studies show that calcium supplements
Daily exercise is critical!
do not seem to prevent fractures3,4 and
Healthy bones need exercise, especially the contribute little to bone density.5,6
weight-bearing kind like walking, climbing stairs, § Calcium supplements appear to be associated
jumping rope, and weight training. This improves with significant risk for harm, particularly an
bone strength as well as balance and flexibility, increased risk of heart disease7 and dementia.8
making us less likely to fall – and lowering the risk
of a broken bone if we do fall. This is especially
important for women at risk for osteoporosis.1
Exercise also strengthens the muscles that support 2
Kemmler, W. et al. Osteoporos Int 2015 Oct;26(10):2491-9
3
Warensjo, E. et al. BMJ 2011; 342:d1473 doi:10.1136/bmj.d1473
the bones. Although physical activity is important 4
Bolland, M.J. et al. BMJ 2015;351:h4580
5
Tai, V. et al. BMJ 2015;351:h4183doi:10.1136/bmjH4183
6
Michaelsson, K. BMJ 2015;351:h4825 doi:10.1136/bmj.h4825
7
Reid, I.R. et al. J Intern Med 2015;doi:10.111/joim.12394
1 8
Kemmler, W. et al. Arch Intern Med 2010;170:179-85 Kern, J. et al. Neurology 2016;87:1-7

Miles Hassell MD © 2016 goodfoodgreatmedicine.com 1

 § In contrast, calcium from food sources appears Dairy as a calcium source
to protect against heart disease.9
Two or three servings per day are probably a
§ There appears to be an increase in age-related reasonable maximum, and the evidence favors
macular degeneration with calcium cultured dairy foods such as aged cheese, yogurt,
supplements in observational studies.10 and kefir (a yogurt-like cultured milk drink) rather
§ Also, avoid supplements with boron and than milk itself. This is not to condemn milk, but
strontium (see below). simply to point out that the greatest historical
evidence for benefit favors cultured dairy foods.
Other nutritional supplements Although I can’t make a strong case, I believe the
I do not recommend over-the-counter nutritional evidence favors whole milk or 2% dairy over 1% or
supplements that claim to build bone, such as non-fat. However, I can make a very strong case
those with vitamin K, boron or strontium. The against sugar delivery systems disguised as dairy
evidence does not support the claims. Before foods, such as sweetened non-fat yogurt (see
taking nutritional supplements consult with a below). But even honest dairy foods are not
physician who is educated in both the benefits and critical to a healthy diet; if you are intolerant of
risks – and as a general principle I recommend you dairy, don’t fret. There are plenty of other whole
think twice before you buy supplements from the food sources of calcium that are not dairy-based.
person who recommends them! Consumerlab.com (See box on left.)
is one of the better information sources regarding
nutritional supplements. ▪Plain yogurt and kefir with live cultures
(probiotics) are immune boosting and have high
available calcium content. (Kefir has a different
Examples of whole foods which deliver spectrum of good microorganisms.) For the best
about 300 mg of calcium per serving: value from yogurt and kefir choose plain
unsweetened, with active cultures clearly noted on
§ 1¼ cups cooked greens like spinach, kale,
the label. Add your own sweetening, such as fruit
chard, or collard greens
or honey – like us, good bugs do better in sugar-
§ ¾ cup edamame (fresh soy beans)
free environments. These helpful microbes even
§ 3 ounces canned sardines (with bones)
partially predigest the lactose in milk, which allows
§ 4 ounces canned salmon (with bones)
some people with lactose intolerance to enjoy the
§ 8 ounces of plain yogurt or kefir
benefits of yogurt. Choose 2% or whole milk
§ 1½ ounces of hard cheese like extra-sharp
versions – non-fat yogurt usually includes additives
cheddar and Parmesan
for flavor and “mouthfeel” to make up for the
§ ½ cup ricotta cheese
missing fat. (Eight ounces of pre-sweetened non-
§ ½ cup tofu (made with the natural coagulant
fat yogurt can include as much as 6–9 teaspoons of
calcium sulphate)
added sugar!) Avoid commercial frozen yogurt – it
is generally junk food. (For more about yogurt, see
pages 32, 135, and 142 of Good Food, Great
Medicine.)
▪ The evidence favors aged cheeses like extra-
sharp cheddar and Parmesan. These traditionally
cultured cheeses have higher levels of vitamin K,
and as they are stronger and richer than softer,
younger cheeses, they have a higher “satiety
factor” (meaning they are more satisfying). This
may be due to their more intense flavor, or
perhaps extended aging affects fats and proteins.

9
Anderson, J.J.B et al. J Am Heart Assoc 2016;5:e003815
10
Kakigi, C.M. et al. JAMA Ophthalmol 2015;133(7):746-54

2 Miles Hassell MD © 2016 goodfoodgreatmedicine.com

Get vitamin D from natural sources Get vitamin K from whole foods
This is a complex issue. Vitamin D levels in the Although the data are fuzzy, it looks like Vitamin K
range of 20–40 ng/ml are associated with healthy from food (especially phylloquinone) is an
bones as well as lower rates of mortality (death),11 important factor in fracture risk reduction.13 Some
obesity, type 2 diabetes, heart disease, high blood of the richer food sources of vitamin K include the
pressure, depression, and some cancers. However, family of leafy green vegetables (especially kale
blood levels above 40 ng/ml may be associated and collards) and naturally fermented foods such
with harm, including higher death rates.11 As with as sauerkraut, kimchi, tempeh or natto (fermented
the case of calcium from food compared to soybeans), or aged cheese. I recommend a daily
supplemental calcium, it appears that naturally serving of leafy greens and one of the fermented
occurring vitamin D may have much better effects foods, if possible – but I do not recommend
than supplemental vitamin D. In fact, after vitamin K supplements.
decades of research it is still unclear whether
vitamin D supplements prevent fractures, Get vitamin B12 from whole foods, too
osteoporosis, or other diseases, and higher levels Low B12 levels increase risk of fracture, and once
of supplementation (e.g. 2,400 units per day) may again, the best way to raise your levels is through
be associated with harm.12 In my practice we aim food. There is no evidence that B12 supplements
for a blood level of 20–40 ng/ml, supplementing help.13 Good whole food sources of B12 are
with 1,000–2,000 iu daily only if we are unable to shellfish, oil-rich fish like salmon and sardines, and
get enough vitamin D from natural sources like oil- unprocessed red meat. Two or three servings a
rich fish and sunlight. (When reading studies that week is probably enough.
discuss blood levels of vitamin D, note which
measuring unit is used: “ng/ml” or “nmol/l.” If you The Mediterranean diet & strong bones
need to compare, multiply ng/ml by 2.5 to convert
to nmol/l.) The omnivorous Mediterranean diet appears to be
associated with lower rates of hip fractures,14
arguably one of the most important measures of
Getting D the old-fashioned way bone health. In contrast, vegetarian diets are
The natural sources of vitamin D are sunlight and associated with more osteoporosis and fractures.15
eating oil-rich fish (like salmon, light or yellowfin Foods most strongly associated with better bone
tuna, sardines, and herring) or cod liver oil. An health include whole foods like vegetables, fruit,
example of sensible sunlight exposure is to expose whole grains, seafood, dairy, and moderate wine
as much of your skin to the sun as you reasonably intake. Processed foods have been found to be
can, without sunscreen, for 10-15 minutes most detrimental to bone health in multiple studies16 –
days in sunny months. The more square inches another good reason to prepare your own food!
that are exposed to the sun, the more vitamin D
you will make. The farther you live from the
equator, the more difficult it is to get vitamin D
from the sun – but avoid getting sunburnt! To
achieve the blood levels thought to be beneficial,
most of our patients require supplements.
Mushrooms exposed to ultraviolet light may be
emerging as another vitamin D source.

13
Sahni, S. et al. Curr Osteoporosis Rep 2015;doi 10.1007
14
Haring, B. et al. JAMA Intern Med. 2016;176(5):645-652
11 15
Kramer, H. et al. PLOS ONE 2012;7:e47458 Tucker, K. AJCN 2014;100(suppl):329S-35S
12 16
Bischoff-Ferrari, H. et al. JAMA Intern Med 2016;176:175-83 Sahni, S. et al. Curr Osteoporosis Rep 2015;doi 10.1007

Miles Hassell MD © 2016 goodfoodgreatmedicine.com 3

 Prunes and black tea Some whole food recipes providing
extra calcium and vitamins D, K, & B12
§ Prunes (dried plums), 5–10 per day, help
Here are some easy-to-prepare whole food recipes
improve bone strength.17 (A favorite snack is a
from Good Food, Great Medicine (3rd edition)
few of Trader Joe’s non-sorbate pitted prunes
which put bone-strengthening principles to work in
with a handful of raw almonds. You can also
your kitchen:
find individually-wrapped Sunsweet prunes at
the grocery store.) Plain yogurt or kefir:
§ Black tea, 3 or more cups a day with or without § Definitive Dip (page 146)
milk (but not green tea), is associated with § Faux Ranch Dressing (page 145)
lower total and 42% lower hip fracture risk.18 § Goop (Rich Yogurt Aioli) (page 144)
(For a good-tasting tea bag, try PG Tips, an § Smoothies (page 136 and 137)
English black tea with pyramid shaped bags.) § Tzatziki (page 145)
§ Yogurt Dessert Cream (page 142)
§ Homemade Kefir (page 143)
Medical evaluation and medications Cooked greens:
There are several approaches to prescription § Green Eggs and Rice (page 244)
medications for osteoporosis, and these vary in § Greens and Beans (page 242)
their effectiveness at reducing the risk of broken § Red Lentil Soup with greens (page 241)
bones as well as side effects and cost. It is § Sautéed Sturdy Greens (page 186)
important to understand that increasing bone § Speedy Spinach Soup (page 182)
density does not necessarily reduce fractures. For § Spinach and Cheese Crepes (page 245)
example, some medicines formerly used to treat § Spinach Frittata (page 134)
osteoporosis were found to increase bone density, § Spinach Timbale (Custard) (page 188)
but actually increased fractures because they made § Creamy Spinach (Palek Paneer) (page 193)
the bones more brittle. Simply improving bone Soy beans and tofu:
density is not enough, the goal is to prevent § Seductive Soybeans (page 202)
fractures. § Soybeans in the Pod (page 202)
§ Before taking any medication or nutritional § Tofu in Soy Ginger Marinade (page 203)
supplement, ask if it has been shown to § Tofu Pâté (page 155)
prevent fractures in patients with your Oil-rich fish:
characteristics. § Sardine Pâté (page 152)
§ Certain medical conditions, some common, § Salmon Cakes (page 227)
predispose to weak bones. § Tuna and Broccoli Pasta (page 231)
§ Also, many medications have the side effect of § Tuna and White Bean Salad (page 232)
weakening bones. Red meat:
So, in addition to exercising daily, eating calcium- § Meat Loaf (page 234)
rich whole foods, getting adequate vitamin D, and § Chili con Carne (page 235)
avoiding calcium supplements and calcium-fortified § Beef Stew (page 236)
foods, it would be wise to discuss the above
aspects of your bone health with your physician.

17
Hooshmand, S. et al. Br J Nutr 2011;106:923-30
18
Prince, R. Am Soc Bone Mineral Research 10/9/2015

4 Miles Hassell MD © 2016 goodfoodgreatmedicine.com

 Sautéed Sturdy Greens
Green Eggs and Quinoa
(Adapted from page 244 of Good Food, Great Medicine) The sauté method works best for the more tender
This is a pro-bone, anti-osteoporosis one-dish meal varieties of sturdy greens like Swiss chard or beet
which also happens to be easy to make. The greens. Both have stems that should be sliced and
greens, onion, cheese, milk, and eggs contribute a sautéed before the leaves. (Spinach, of course,
veritable symphony of calcium and vitamins D and barely needs cooking at all.) These greens can be
K to feed and strengthen your bones and the bones served alone as a side dish or with cooked whole
of those you love. Frozen spinach is the easiest grains and beans for a main dish.
option, but barely-steamed fresh spinach, cooked (About 3 cups cooked greens)
kale, and chopped leftover broccoli are additions 1½ pounds of greens, cleaned, stemmed, and
we love. You can use brown rice instead of quinoa, chopped, about 2 bunches (see page 166)
crumbled feta cheese instead of cheddar, and so -or- about 12 cups of chopped greens
on. You can prepare it in advance through step 2 3–4 tablespoons extra-virgin olive oil
(store it in the refrigerator if overnight), bringing it Optional: a pinch of crushed red pepper flakes
to room temperature and mixing again before 1 teaspoon freshly crushed garlic
transferring to dish. The leftovers reheat well.
1. Heat olive oil over medium heat in a large deep
(Serves 4 as a main dish, more as a side dish) skillet (10-12-inch), pot, or wok.
2–4 tablespoons extra-virgin olive oil 2. Add garlic and optional pepper flakes, and
1 medium-large onion in ¼-inch dice (2–3 cups) sauté for about 10 seconds. (Avoid browning
6 eggs the garlic!) If you have sliced stems, add and
1 cup whole milk sauté until tender, about 10 minutes.
1 teaspoon salt 3. Add chopped greens. If you add them one big
1 teaspoon freshly ground black pepper handful at a time, tossing and turning them in
6 oz (about 2 cups) grated sharp cheddar cheese the hot pan as you go, you will find them easier
½ cup grated Parmesan cheese to manage.
1½ cups cooked quinoa (page 208) 4. Continue to toss and turn the greens until they
16 ounces frozen spinach, thawed are tender enough for your liking. (Some like
Preheat oven to 300 degrees. Oil an 8x8 or 9x13- greens al dente, others like them very tender.)
inch (2–3 quart) Pyrex baking dish or similar. Kale and collards take longer than chard or
1. Heat oil in a sturdy 10-inch skillet over beet greens.
medium-high heat and sauté onion for about Note:
10 minutes or until very tender. Remove from 4 Sautéing already-blanched greens: Blanched
heat and set aside. greens don’t need much (if any) cooking. We
2. Whisk eggs in a mixing bowl or an 8-cup Pyrex suggest always blanching the tougher greens like
jug. Add milk, seasoning, cheeses, cooked kale and collards before sautéing. Follow
quinoa, spinach, and sautéed onions, and mix directions above but add all the blanched greens at
very well. once and sauté until hot through and tender
3. Scrape into oiled baking dish and bake enough for your taste.
uncovered for about 60–75 minutes (it will
4 Serving suggestions: The simplest treatment is
cook more quickly in the larger baking dish) or
just a generous sprinkle of freshly grated Parmesan
until no longer wet in the center.
on the hot greens. Other ideas: toss with a
Note: tablespoon or two of vinaigrette; toss with toasted
} Adding ½-pound of fresh sausage to the sautéed pine nuts or slivered almonds and a handful of
onions in Step 1 will kick up the flavor and the raisins; add a couple of cups of cooked garbanzo
crowd-pleasing qualities. Just push the onions to beans (chickpeas) and crumbled feta cheese, and
the side and sauté sausage until browned and well serve over hot brown rice or quinoa.
crumbled.

Miles Hassell MD © 2016 goodfoodgreatmedicine.com 5

 Miles Hassell MD is an internist in private
practice at Providence St. Vincent Medical
Center in Portland, Oregon, where he lives Good Food
with his wife Anna and son Tor. He was born
in Seattle, Washington, and was raised in
Perth, Western Australia, receiving his medical
Great Medicine
degree from the University of Western Third Edition
Australia. He completed his residency in Miles Hassell MD
Internal Medicine at Providence St. Vincent Mea Hassell
Medical Center.
Dr. Hassell established the Integrative
Medicine Program at Providence Cancer
a Mediterranean
Center in Portland and is a clinical instructor in diet and lifestyle guide
the training of Internal Medicine residents, to eating well
twice named Outstanding Teacher of the Year.
He also lectures widely to physician groups
about the appropriate integration of lifestyle
and conventional medicine, and is often The 288 easy-to-read pages present powerful
interviewed on health issues by local television medical evidence to support adopting a whole food
and radio. He is the co-author of Good Food, Mediterranean diet-and-exercise based lifestyle,
Great Medicine, an evidence-based guide to with 185 simple-to-follow recipes using everyday
using a whole food Mediterranean diet in the ingredients. The 14-step
pursuit of optimal health. Risk Reduction Action Plan helps:
In his private practice Dr. Hassell § prevent or reverse heart disease and stroke,
encourages the vigorous use of evidence- type 2 diabetes, insulin resistance, and
based food and lifestyle choices and has been metabolic syndrome
chosen as one of Portland’s Top Doctors. Dr. § improve cholesterol and blood pressure with
Hassell is available for individual consultations fewer drugs
for diagnosis, second opinion, or to develop § lose weight without deprivation
patient-centered solutions using evidence- § reduce dementia and cancer, and improve
based conventional and lifestyle interventions. cancer survivorship
This is a practical resource for anyone looking for
an evidence-based approach to eating well without
Miles Hassell MD sacrificing eating enjoyment.
Internal Medicine + Lifestyle Medicine
Comprehensive Risk Reduction Clinic (Available at: Amazon, Powell’s Books,
9155 SW Barnes Road, Suite 302 Annie Bloom’s Books, County Libraries:
Portland, OR 97225 Multnomah - Clackamas - Washington - Clark,
Providence Integrative Medicine Program.)
Voice: 503.291.1777
Fax: 503.291.1079 For bulk discounts or questions call 503.291.1777.
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6 Miles Hassell MD © 2016 goodfoodgreatmedicine.com