Context:
Optimal levels of vitamin D have
been a topic of heavy debate, and the correlation between 25-hydroxyvitamin D
[25(OH)D] levels and mortality still remains to be established.
Objective:
The aim of the study was to
determine the association between all-cause mortality and serum levels of
25(OH)D, calcium, and PTH.
Design and Setting:
We conducted a retrospective,
observational cohort study, the CopD Study, in a single laboratory center in Copenhagen,
Denmark.
Participants:
Serum 25(OH)D was analyzed from
247,574 subjects from the Copenhagen general practice sector. In addition,
serum levels of calcium, albumin-adjusted calcium, PTH, and creatinine were
measured in 111,536; 20,512; 34,996; and 189,496 of the subjects, respectively.
Main Outcome Measures:
Multivariate Cox regression analysis
was used to compute hazard ratios for all-cause mortality.
Results:
During follow-up (median, 3.07 yr),
15,198 (6.1%) subjects died. A reverse J-shaped association between serum level
of 25(OH)D and mortality was observed. A serum 25(OH)D level of 50–60
nmol/liter was associated with the lowest mortality risk. Compared to 50
nmol/liter, the hazard ratios (95% confidence intervals) of all-cause mortality
at very low (10 nmol/liter) and high (140 nmol/liter) serum levels of 25(OH)D
were 2.13 (2.02–2.24) and 1.42 (1.31–1.53), respectively. Similarly, both high
and low levels of albumin-adjusted serum calcium and serum PTH were associated
with an increased mortality, and secondary hyperparathyroidism was associated
with higher mortality (P < 0.0001).
Conclusion:
In this study from the general
practice sector, a reverse J-shaped relation between the serum level of 25(OH)D
and all-cause mortality was observed, indicating not only a lower limit but
also an upper limit. The lowest mortality risk was at 50–60 nmol/liter. The
study did not allow inference of causality, and further studies are needed to
elucidate a possible causal relationship between 25(OH)D levels, especially
higher levels, and mortality.
Note: 50-60 nmol/L equals 20-24
ng/ml. To convert nmol/L to ng/ml, divide by 2.5. To convert ng/ml to nmol/L,
multiply by 2.5.
The full article is available here:
15 comments:
Hi Bone Lady!
I used to take Sr but quit after weight gain. But heavens, my latest bone density scan shows osteoporosis in my arm (only the arm!...hip and spine still OK). My Ob/gyn is saying she doesn't know why. I'm not on fosamax yet (thank god!). I had a kidney stone removed last year (another still stuck on the other side!) so I'm trying to be good but I want to take Sr again. Ob/gyn has no problem with that.
I'm wondering what you think about taking half dose (one daily capsule) instead of the full dose (two daily capsules). I want to be conservative but don't have much clue.
thanks for all you continue to do to spread the word.
Kathy
Kathy,
Why was your arm scanned along with the spine and hip? Usually, only the spine and hip are checked for osteoporosis. The forearm may be scanned if hardware or severe scoliosis or arthritis in the spine or hip prevents an accurate reading.
A half dose (340 mg) of strontium works well in many cases. It may work for you.
The recommended amount of strontium to prevent osteoporosis in those with osteopenia is 340 mg.
I know a lady who took 640 mg strontium daily for two years for her severe osteoporosis and then reduced her dosage by half although she was still osteoporotic. She has been at the reduced dose for two years, and her BMD keeps getting better with each DXA scan.
Read “6 Easy Ways to Prevent Kidney Stones.” https://www.kidney.org/atoz/content/kidneystones_prevent
Also, read “Diet and Kidney Stones.” https://www.kidney.org/atoz/content/diet
In one clinical study, patients with histories of recurring calcium oxalate kidney stones were given 200 mg of magnesium oxide and 10 mg of vitamin B6 (pyridoxine) daily for extended periods of time. Thirty of 36 patients maintained on this program for 5 years or more showed no recurrence or decreased recurrence of stone formation. http://ajcn.nutrition.org/content/20/5/393.short
Some alternative health enthusiasts are saying that vitamin K2 might reduce incidence of kidney stones. I don’t know if they are right or not.
It’s nice to hear from you again.
Thank you so much for your thoughts! I'll do the half-dose for a year and see how my next scan looks.
I've been reading your website all along. I've suffered from some closed-minded discussions with some of my doctors about the strontium. I had a stand up row with one of my dentists (I go to the teaching hospital and see quite a few experts there). The bottom line is: if there's been no 'proper' research study, with thousands of patients and double-blinding etc. they don't wanna hear it. It's driven me into the closet! My dental issues are one reason I don't wanna even try Fosamax.
I thought I'd stop the Sr for a while and see how the weight issue went. But there's so much other stuff going on (diverticulitis too!)....who knows! It probably wasn't the fault of the Sr at all!
I don't know why they scanned my arm, in addition to hip and spine. I do know the scan-lady (met her a decade ago during my days in an OP research study) and she's terrific. I never thought to ask. I thought that's just what they do here. They always scanned arms during the study (DH was also on a study at another facility here...they did that too).
The kidney stone landed me in hospital but the doctor didn't want to analyze the stone! He said the composition wasn't important and I should just drink a lot more water (or face repeats).
I've got minor bladder issues (like many older women) and the water can be an issue (if I'm headed out). Catch 22!
Thanks so much for those links! I'll go read them.
How often do you have bone scans?
Kath
Kathy,
Your doctor is right about the need to drink lots of water (12 cups per day) to prevent kidney stones.
There are nonprescription and prescription medications to control overactive bladder, but check with your doctor before taking any of them.
Your doctor is wrong about the composition of the stone not being important. Most people have calcium oxalate stones, but other types of stones are uric acid, struvite and cystine stones. Each type has a different cause, and each may need a different kind of treatment or prevention.
Doctors often prescribe potassium citrate to prevent kidney stones, but lemonade also works. http://www.webmd.com/kidney-stones/news/20060524/lemonade-helps-kidney-stones
You may be able to prevent diverticulitis if you drink plenty of water, get regular exercise, and eat a high-fiber diet. Here we go with the water again.
I’ve never heard of strontium causing weight gain and don’t know how it possibly could; it’s a mineral. The same advice for preventing diverticulitis can help prevent weight gain.
I have gotten bone scans on a very irregular basis and have only had three. The first one diagnosed me with osteoporosis. The second one was about two years later. The third one was about four years after that. August 21, 2015 will be two years since the third one, and I am not getting another DXA this year. My second DXA showed significant improvement, but the third one was a show stopper! I was well into the osteopenia range! I am in no rush to get another scan, because I know, as long as I stay on strontium, the scans will keep showing improvement. I am still taking the full dosage, although my BMD is probably in the normal range now. I may get a DXA next year or the year after. If I am normal, I’ll reduce my strontium dosage to half.
I hope the half dose of strontium works for you. I hope all your health issues are resolved or greatly improved.
Thank you Bone Lady,
I felt at the mercy of the hospital doctor re the kidney stone. One is not in a position to argue! If/when the other stone comes down, maybe I'll get another doctor or I can persuade him to analyze it.
He told me to stop drinking black tea! Now, for a Brit...that's a disaster. I've cut it back to one a day but I must admit, I'm suffering withdrawal. I'm wondering why the entire U.K. isn't suffering from kidney stones. Or why it took me 65 to form one!
You don't think there's any chance it could have been related to Sr, do you?
Re the lemonade, do you think the bottled concentrate is OK? I do have some Crystal Light (traditional lemon flavor) but I suspect that's not so good (it sure is easy to use!).
My GP gave me oxybutynin for the urine problem but I've taken only one pill. The trouble is, it thickens up the saliva and since I wanted to use it on my long journeys to the dentist, I'm rather stumped again!
Thank you again...I'm getting to be a pain! On fiber: The colonoscopy doctor told to take Metamucil daily, which clogged up my gut and nearly put me back in emergency! I'm eating peanuts and popcorn in good form. I 'take' broccoli also but do you know of anything else I could take that wouldn't stop my gut?
Kathy
Kathy,
Don’t resume taking strontium citrate. It may have been an important factor in your kidney stone formation. Strontium is present in the human diet in trace amounts that vary with geographic location. Strontium is processed by the gut and kidneys in a manner similar to calcium. A recent study in the US using advanced x-ray fluorescence imaging identified strontium in all calcium based stones, present as strontium apatite. This finding may be critical since apatite is thought to be the initial nidus for calcium stone formation. Strontium is not identified by standard laboratory stone analyses.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4124908/
Your doctor told you to stop drinking black tea because it has high oxalate levels. You can switch to oolong tea or one of the herbal teas listed in the link below. He’s assuming your stones are calcium oxalate stones. It’s an assumption with a high probability of being correct because those are by far the most common type of stones. A kidney stone specialist (urologist or nephrologist) would order a stone analysis, but the lab would not find strontium in any stone. As noted in my first paragraph, strontium is not identified by standard methods.
So, let’s assume your stones are calcium oxalate and also contain strontium apatite. You would need to stop taking strontium as a supplement, reduce your salt intake, drink lots of water, and follow a low-oxalate diet. http://www.upmc.com/patients-visitors/education/nutrition/pages/low-oxalate-diet.aspx
You’re wondering why the entire UK, a nation of black tea drinkers, isn’t suffering from kidney stones. That’s because some people form stones and others do not. Hypercalciuria, or excessive urinary calcium excretion, is the most common identifiable cause of calcium kidney stone disease.
You’re wondering why it took you till age 65 to form one stone. Postmenopausal women with low estrogen levels have an increased risk for kidney stones. Also, you had added strontium citrate to your supplements.
Bottled lemon juice from concentrate contains preservatives. Lemonade made from frozen concentrate or fresh lemons would be better.
Oh heck! Thanks so much! Dammit, I do have high Ca in the urine. 371 mg/24 hrs (instead of 100-250 normal).
In fact, Ob/gyn (who ordered that test recently after my arm showed up in the OP range) told me to cut the Ca supplement in half (down to one 600 mg pill per day). That seemed sensible since I upped my Ca to take FDA recommended levels of Ca (2 pills/day) only a couple years ago.
So, not only had I doubled Ca intake but I had started taking the 680 mg of Sr (this was 2012-2013) which probably set off the seed for the stones. Urk! Ya win some, ya lose some!
Wow...but I still have the OP problem. I'm thinking about maybe splitting a Sr capsule and taking half of 340 mg every day instead. I'd love to know what you think. I've still got one little kidney stone waiting to drop on my 'other' side.
Thanks for the tea thoughts...sigh!
Do you think the 'lemon' portion of the lemonade is what's important or is it simply the potassium citrate? I took a look at the Crystal Light label. It's mostly citric acid (potassium citrate + some sodium citrate). I take it pretty weak (3 quarts water instead of 2). There's almost 2 g of the chemicals in one packet. The beauty of that stuff is, you just dump a packet into a 3 qt bottle, fill with water and store in fridge....easy peasy!
Thank goodness I have you to discuss this with. My various doctors seem as varied in their opinions as I am confused in mine. The kidney stone guy was a specialist. He was the hospital chief surgeon in fact (as his junior had to take emergency leave). Junior believed in stone analysis but senior did not! Oh well, it wouldn't have helped anyway. I've got a lot to think about.
thanks again, Kathy
Kathy,
I think a lot of people besides you have been taking too much supplemental calcium because they misinterpret the calcium recommendations. The recommendation for calcium for adult women 51 and older is 1200 mg per day. That is the recommendation of the National Institutes of Health (NIH) and the National Osteoporosis Foundation (NOF). That is the TOTAL amount recommended from ALL sources.
Decide how much calcium you are getting from your diet, and then supplement the rest. My diet provides about 550 mg calcium daily. My Ca/Mg supplement contains 500mg calcium. My multivitamin contains 162 mg calcium. Added together, that’s 1,212 mg calcium.
Citrate is the substance in lemonade that helps prevent kidney stones. When made into low-sugar or sugar-free lemonade, lemon juice increases the amount of citrate in the urine to levels known to inhibit kidney stones. It doesn't work quite as well as potassium citrate. But for patients who'd rather avoid yet another medication, lemonade is an attractive alternative.
I found the ingredients in Crystal Light:
Citric Acid, Potassium Citrate and Sodium Citrate, Maltodextrin, Aspartame, Magnesium Oxide, Natural Flavor, Acesulfame Potassium, Soy Lecithin, Artificial Colors
Because Crystal Light has citric acid,potassium citrate,sodium citrate, and no sugar, it should work. After all, potassium citrate is what many doctors prescribe to prevent kidney stones. I would not take it myself due to the artificial sweeteners and colors.
You said only your forearm showed osteoporosis. You have never mentioned fractures. The FRAX tool to evaluate fracture risk uses the femoral neck BMD. So, your fracture risk may be lower than you think. Here’s a link to the calculator for the UK: http://www.shef.ac.uk/FRAX/tool.aspx?country=1
If I were forming kidney stones, I would not take any amount of strontium after reading that study about kidney stones containing strontium, which may be the seed that starts stone formation. The researchers seem to be assuming all the strontium came from food. I wonder if some of the patients had been taking strontium citrate.
Thank you again Bone Lady,
I'm truly kicking myself that I gave in after pressure from my GP and my Ob/gyn and upped my dosage of supplementary Ca from 600 to 1200 mg daily. Until a few years ago, I was taking only 600 mg supplement daily (as I do eat cheese/dairy also) as I figured it was better not to take too much. They thought differently and turns out they were wrong: so now I really don't know if I should totally blame the Ca or if the Sr may have been the cause the stone began.
The kidney specialist told me that they have no idea how long my kidney stones have been in formation. Do you know if private labs do the flourescence test? Of course, I'd still have to wait for the other stone to descend before I could even do that.
I worked out my score on that calculator (thanks for giving me that link again) and it's 8.1% 10 year probability of fracture and 1.2% specifically for the hip. However my arm scan showed T score of -3.3 in the 1/3 radius, so I'm still scared. Ob/gyn says that bones will break even at -1 (which I didn't know) but -3.3 sounds pretty fragile to me.
The results of OP, of course, are horrendous long term and as you have noted, Fosamax etc. cause problems and many people cannot take it. I watched my own mother suffer terribly with it and now I must decide which way to go with devils blocking each option.
Shoot....wouldn't it be lovely if some rich person would fund more research on Sr. especially on folks who've had kidney stones and would rather suffer all the horrors of OP than go through that pain again.
Kathy
Kathy,
Shame on your GP and Ob/gyn! They should have known better than to up your supplemental calcium dose to 1200 mg, when you were regularly eating cheese and other dairy products. So, kick them (mentally), not yourself! My diet contains milk, yogurt and cheese. That’s why I only supplement 662 mg calcium.
I don’t know what started your stone formation or when the process began. As you wrote, even the kidney specialist doesn’t know when your stone began forming. The extra calcium you started taking was certainly a bad idea. Did the strontium contribute to, or begin, the process of stone formation? I don’t know. The researchers who wrote “Strontium Substitution for Calcium in Lithogenesis” think strontium might start calcium stones, but that is just their theory. The same researchers have done other work on kidney stones. Their work may lead to more knowledge of how stones form. They also wrote “Microcomposition of Human Urinary Calculi Using Advanced Imaging Techniques.” http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4124914/
No, the synchrotron radiation based microfocused x-ray fluorescence test and the other specialized tests are not done in private labs. They are run in only a few research labs with synchrotrons (huge machines).
This is an excerpt from the article sited above:
“Common methods of commercial urolithiasis analysis, such as light microscopy and Fourier transform infrared spectroscopy, provide limited or no information on the molecular composition of stones, which is vital when studying early stone pathogenesis. We used synchrotron radiation based microfocused x-ray fluorescence, x-ray absorption and x-ray diffraction advanced imaging techniques to identify and map the elemental composition, including trace elements, of urinary calculi on a μm (0.0001 cm) scale.”
Your FRAX scores look good, especially the probability for hip fracture.
I’m hoping those California researchers keep up their good work on kidney stones.
Yeah, I sure hope those researchers will keep it up. Mind you, they can't really be giving people strontium at various dosages to see which level does not assist stone seeding. They'd need some very tough-minded subjects (or ignorant ones har har!). And if they take folks with existing stones (like me) they won't be able to control the study. And how are they going to find subjects with kidney stones with the sort of supplement history that fits. Heck!
I suspect I'm not the only one! While Googling I came across a closed chatboard with a gal who was convinced Sr caused her stone. Everyone was advising her that could not be but she swore there was nothing else new in her intake.
Well, keep up the good work...and thank you again! I am going to give this some serious thought and perhaps lay off the Sr supplements until my current ob/gyn lays it on me about Fosamax. By then, maybe I can face the thought of risking more kidney stones.
Hey...FWIW, I started getting tonsil liths during the Sr period too! And they are pretty rare! Some of my dental experts had never heard of them. I still get them occasionally but nothing like so often as when I was taking the Sr.
Kath
Kathy,
I sent an email to one of the researchers who wrote the articles on kidney stones. I asked Dr. Stoller if he would analyze your stone, and he said he would be happy to! He wrote me right back and was so nice! Here is his contact information:
Marshall L. Stoller, M.D.
Professor and Vice Chair
Department of Urology
University of California San Francisco
Phone: 415 476-1611
Fax: 415 476-8849
Email: mstoller@urology.ucsf.edu
I also asked him the following: Do you know if any of the people whose stones you analyzed were taking strontium citrate as a supplement for osteoporosis? I know strontium is found in food and water. Are you aware many people, myself included, are taking large quantities of strontium (about 2 grams strontium citrate with 680 mg elemental strontium) on a daily basis? Your paper implied strontium could be the nidus, or beginning, of calcium oxalate stones.
He answered, “We do not know if elevated strontium in your diet or those with strontium intake (tablets) are the ones with elevated strontium in their stones.”
I told him you had reduced your calcium intake and stopped taking strontium citrate. I said you had cut back on your supplemental calcium but didn’t state it was because you had been taking excessive amounts.
He wrote: “Your friend should not stop taking calcium supplements. Our studies and many others have shown that those with the lowest dietary/supplement calcium intake have the highest recurrence rate. It is counter-intuitive.”
Kathy said…
Hi Bone Lady,
Thank you so much for all this research on my behalf and for digging me up via my old blog.
I shall certainly write to Doctor Stoller. Unfortunately, I'll have to wait for the 2nd kidney stone to descend as I didn't think to ask the hospital for the 1st one, so I assume it's lost.
That's very interesting about the recurrence rate of stones being related to low calcium intake. Who'd ha thunk it! Do I understand you correctly when I'm reading that it's a low total (diet and supplemental) intake of calcium that results in recurring stones? Did he say how low?
Kathy
April 13, 2015 at 9:58 AM
Kathy,
Yes, Dr. Stoller said those with the lowest total calcium intakes from diet and supplements have the highest recurrence rates for stones. He did not say how low. My understanding is that a calcium oxalate stone former should take the same amount of total calcium recommended by NIH for a person of the same sex and age who does not form stones. http://ods.od.nih.gov/factsheets/Calcium-Consumer/
This article from the National Kidney Foundation on “6 Easy Ways to Prevent Kidney Stones” says the same thing. “A diet low in calcium actually increases one's risk of developing kidney stones.”
“Instead: Don't reduce the calcium. Work to cut back on the sodium in your diet and to pair calcium-rich foods with oxalate-rich foods.” https://www.kidney.org/atoz/content/kidneystones_prevent
Kathy,
Chlorthalidone, a diuretic (water pill), prevents calcium stones by stimulating reabsorption of calcium in the kidney, thus decreasing the amount of calcium in the urine. Because it can decrease blood potassium levels and reduce citrate levels in the urine, potassium citrate is sometimes given with chlorthalidone to correct both the low potassium and low citrate. Fatigue and dizziness have been reported by patients on diuretics.
So, if you decide to try this diuretic, be sure to get a prescription for potassium citrate and/or eat lots of potassium-rich foods (e.g., bananas, prunes, raisins, and orange juice) each day. Also, follow a low-salt diet and drink lots of water and lemon juice.
Here is a good website: http://www.kidneystoners.org/prevention/preventative-medications/
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