Ask the Nutritionist: Calcium Supplements, Yes, No, WTF?

Got questions about healthy eating and nutrition?

Well, today starts a new feature at Cranky Fitness: Ask the Nutritionist!

It could also rightfully be called "Ask the Dietitian," since both the contributors are RD's. I almost did call it that, but then decided to play it safe in case either of these two knowledgeable and articulate experts figures out what a silly blog this is and decides to bail.  What if I need to find someone new and have to cast a wider net?

 No certification, but pretty darn sensible!

Plus, half the time I spell it "Dietitian" and the other half "Dietician" and that was driving me kinda crazy.

Anyway, so today's topic is calcium supplements.  Used to be simple, right? If you weren't getting tons o' dairy, and especially if you were female, you were supposed to take 'em.

And my doctor still says I should, and studies are confusing. But even Jane Brody of the New York Times, not exactly known for going out on a limb with controversial advice, points out the risks of calcium supplementation, which include a higher likelihood of heart attacks and strokes.

So what's the deal?

Since Crabby is incapable of keeping things simple, by say, asking "should you take calcium supplements if you don't eat a lot of dairy?"... please stand by for a long-ass compound question:

What are the best strategies for non-dairy calcium?

Studies seem to suggest calcium supplementation has risks. Yet many folks are avoiding dairy either due to allergies, intolerances, vegan leanings, primal or low carb diets, or traumatic cafeteria experiences in 3rd grade. When you start to add up supposedly "good" sources of non-dairy calcium, it seems like you need to eat about a football field full of leafy greens and other dairy alternatives to hit the requirements, or else resign yourself to supplements and risk croaking from cardiac arrest or strokes. Post-menopausal women in particular seem to struggle with what to do about it.

What are some strategies for optimizing calcium intake, and how dangerous do you think supplements really are?

And what about "fortified" foods that don't naturally contain calcium, like almond milk or orange juice? Are these any different from taking a calcium supplement in tablet form when it comes to risks of strokes or heart attacks?

So let's meet our dietitians and see what they have to say!

Marsha Hudnall

Marsha Hudnall, MS, RD, CD, is president and co-owner of Green Mountain at Fox Run, a healthy weight retreat in Vermont that is exclusively for women. Forty years ago, Green Mountain pioneered the non-diet, mindful/intuitive eating, healthy living approach which includes a team of registered dietitians, psychologists and exercise physiologists. Marsha is a frequent speaker to both lay and professional audiences and has written for a wide variety of popular and professional publications. She serves on the board of The Center for Mindful Eating and the Binge Eating Disorder Association. Her newest book "Eating Happy: A Woman's Guide to Overcoming Overeating" will be available summer 2013.

This is an excellent question to kick off Ask-a-Nutritionist on Cranky Fitness. That's because, to me, it epitomizes the confusion people have around nutrition.

I want to say first that Laura is probably much more supplement-savvy than I am, as most of my work is in helping women learn how to feed themselves well with real food. I gladly point this out because I think it is critical to know what you are doing when taking supplements. There are tons of potential interactions that could spell trouble when people take supplements indiscriminately, especially in large doses. So, imo, it is very important to work with a knowledgeable professional to guide you.

To answer your question about calcium and calcium supplementation in particular, though, it's pretty clear that eating sensibly such as with a Mediterranean-style diet gives you your best start on getting the nutrients you need and optimally utilizing them, including calcium. You can read more about the Mediterranean diet and calcium here.

We all know, however, that most Americans don't eat like the Mediterranean diet suggests. The good news is that even though it leaves a lot to be desired in other areas, the average American diet that doesn't include dairy foods still contains about 300 mg or so of calcium a day. To boost that without using dairy foods, you can add things like canned fish with bones, tofu, or other foods fortified with calcium, such as plant milks like almond, soy, etc. That football field of leafy greens you mentioned? Actually, a cup of a cooked leafy greens like kale or bok choy or cabbage provides almost as much calcium as a glass of milk. Those leafy greens are also good sources of magnesium and vitamin K, which is important to calcium absorption and utilization. Adequate vitamin D is also important.

If you do supplement, experts agree to not take large doses, such as 1000 mg or more a day, to avoid any of the problems that recent studies suggest may be associated with larger supplemental intakes. If you're eating as I described above, you shouldn't need more than 250 to 750 mg/day (higher needs for menopausal women) in supplemental form to meet recommended intakes. That keeps you well within what is considered a safe range. You still need to be getting the other nutrients I mentioned above, though. Otherwise, you won't be optimally absorbing or using the calcium you take.

Laura Lagano

Laura Lagano is a holistic registered dietitian who counsels individuals about nutrition in Hoboken, NJ. What makes her service unique is the location – her kitchen. As opposed to an office or clinic, Laura’s “Nutrition in my Kitchen” program shows clients how to put her recommendations into practice. Applying the principles of functional medicine to nutrition and lifestyle counseling, Laura develops food and health plans by addressing the underlying triggers of disease, rather than symptoms. She also has a New York City nutrition office and offers Skype appointments. Reach Laura at or 917-829-0250.

Though Vitamin D is the current darling in the nutrient line-up these days, calcium is still talked about just as much as ever. More people are shunning dairy and not simply because of an allergy or lactose intolerance. In some nutrition circles, dairy elimination is synonymous with better health. Dairy proponents, however, say that avoiding this food group will result in poor calcium intake. No one will debate that dairy products are currently a primary source of calcium for most Americans. If you do not eat dairy products for whatever reason, how do you get your calcium?

Consider these facts. One, the calcium amount indicated on food labels is listed as a Percent Daily Value based on an intake of 1000 mg, which hovers around the Dietary Reference Intake (DRI) for adults. All of these numbers are most helpful for population, not individual, guidelines. Differences, for example, in health status, genetic variability, biochemical individuality, and lifestyle habits can change your personal, optimal nutrient intake.

Two, the DRI for calcium considers the Standard American Diet, also known as SAD. This is the actual acronym used by nutrition professionals. And sad it is. Because processed food and carbonated beverage consumption with its excessive amount of phosphorus is so high in the US, the DRI value for calcium is higher. That’s because calcium and phosphorus need to be in proper balance with one another for optimal functioning.

In my private practice, I rarely recommend calcium supplementation. Excessive calcium can cause more harm than good. Too much has the potential to displace magnesium and potassium, both vital to heart health. Though we associate low calcium with osteoporosis, many other minerals contribute to bone loss.

Before we review foods that are good sources of calcium, keep in mind that we are what we digest and absorb rather than what we eat. Calcium, like all minerals, requires a very specific gastrointestinal environment for absorption. As Americans the three major factors that interfere with absorption are (1) drinking carbonated beverages, (2) taking antacids, and (3) low hydrochloric acid. You can change numbers 1 and 2 easily. Low hydrochloric acid, commonly referred to as stomach acid, can be rectified with appropriate supplement therapy of betaine hydrochloride under the supervision of a healthcare professional. Calcium intake is not simply about eating calcium-containing foods.

For those who still ask what foods are good sources of calcium other than dairy, let’s take a look at milk alternatives. What would you pour into that bowl of granola or buckwheat groats (I’m not kidding; they’re delish!) if cow’s milk wasn’t part of your food plan? The choices are much wider and more available nowadays. All of these beverages are available in calcium-fortified versions and some contain calcium put there by Mother Nature.

Non-Dairy Milk Alternatives:
• Coconut milk
• Almond milk
• Hemp milk
• Rice
• Hazelnut
• 7-Grain
• Oat milk
• Soy (look for a verified Non-GMO label)

Perhaps you don’t drink milk of any kind. You still need calcium, so what do you eat? Pound for pound, leafy greens beat out dairy every time. Yes, that would be a lot of greens. Remember, it’s not only about the calcium you eat or drink, it’s about several other things that influence your absorption of this mineral. To pack a wallop of calcium, my suggestion is to have a green smoothie (check out my recipe below), green juice, or trail mix as often as possible. Check out my recipes below.

Great Non-Dairy Calcium Foods:
• Kale
• Turnip greens
• Dandelion greens
• Mustard greens
• Collard greens
• Arugula
• Broccoli
• Figs
• Sardines
• Canned salmon
• Soy beans (look for this label)
• Sesame seeds
• Almonds
• Brazil Nuts
• Flax

The Greenest Smoothie

3 ounces baby kale or dandelion greens (remove fibrous stems)
2 cups plus additional purified water
3 ounces arugula
4 stalks celery, cut into large pieces
1 small bunch parsley leaves
1 avocado
1 green apple, cored and sliced
1 lemon, peeled & seeded

1. Place kale or dandelion greens in high-speed blender. Add 2 cups water and blend on low, increasing speed until liquid.
2. Add additional ingredients one at a time until liquefied.
3. Add water to reach the 64 ounce mark.

Makes 4 16-oz smoothies

Bottomline Tips for Optimizing Calcium Absorption:
1. Limit how much processed food you eat.
2. Stop drinking soda!
3. Cut out the antacids.
4. Make sure your stomach acid is adequate. Consult with a dietitian/nutritionist who is trained in functional medicine to help you figure this out.
5. Drink a green smoothie or green juice as often as possible. I start my day with one every morning.
6. Toss canned fish in a salad with high-calcium greens.
7. Make a trail mix of raw almonds or Brazil nuts, sesame seeds, and cut up dried figs. Carry it with you for a high-calcium, high protein snack throughout the day.
8. Be creative. Make a pizza with goat cheese (okay, this is dairy) and sliced fresh figs. After it’s baked, liberally cover with arugula.
9. Make edamame, a preparation of immature soybean pods briefly steamed. Make certain any soy products you use do not contain genetically-modified organisms.
10. Add ground flax to cereals, salads, protein drinks. Go slowly at first because flax can really move things along in your digestive tract.

Thanks, Marsha and Laura!

So what do you folks do about calcium? Or is it something you even think much about? Got any questions for future columns?

Knudsen photo: Lileks
Bunny: all over the web; original source unknown

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