Supplements for Bone Health: A Special Note for People with HIV

Bone health has been a growing concern for people with HIV, since studies have indicated that HIVers experience higher than expected rates of osteopenia (bone mineral density lower than normal) and osteoporosis (bone mineral density very low, with heightened risk of fractures). A 2012 review from Johns Hopkins researchers, for example, concluded that the “increasing prevalence of osteoporosis in HIV-infected persons translates into a higher risk of fracture, likely leading to excess morbidity and mortality as the HIV-infected population ages.”

The Johns Hopkins study urged more attention to Vitamin D deficiency and supplementation as one way to counter these HIV-related bone issues. But we think it’s also worth looking at recent Canadian research, not focused especially on people with HIV, but with some striking findings about the value of multiple supplements to support healthy bone mineral density levels. The supplements investigated included vitamin D(3), vitamin K(2), strontium, magnesium and docosahexaenoic acid (DHA), all chosen because of previous evidence about their benefit to bone health. Following a year-long study of patients with varying levels of bone loss, the Canadian researchers determined that this supplement regimen was as effective as a class of drugs often prescribed for osteoporosis (bisphosphonates, such as Fosamax or Boniva). And, they found that the combination of supplements was even effective for people who had failed to benefit from the prescription osteoporosis drugs.

We hope to see further study of supplement combinations for bone loss in people with HIV. It’s an acknowledged problem as HIVers get older, and if there’s a potential way to lower this health risk over the long run, let’s take a serious look at it!

Note: NYBC stocks Jarrow’s Bone Up or Ultra Bone Up, plus Max DHA or EPA-DHA Balance, which provide most of the micronutrients in the Canadian study (missing is the Strontium, but NYBC hopes to have a recommendation for that in the near future).

Visit the NYBC website for more information:

http://www.newyorkbuyersclub.org/

References:

The Johns Hopkins study: Walker Harris V, Brown TT. Bone loss in the HIV-infected patient: evidence, clinical implications, and treatment strategies. J Infect Dis. 2012 Jun;205 Suppl 3:S391-8. doi: 10.1093/infdis/jis199.

The Canadian study: Genuis SJ, Bouchard TP. Combination of Micronutrients for Bone (COMB) Study: bone density after micronutrient intervention. J Environ Public Health. 2012;2012:354151. doi: 10.1155/2012/354151.

Media Distortions, as usual…

The news says: Elderly ladies, stop the Ca+D. The title here, for example:
USPSTF Says No to Vitamin D, Calcium for Older Women

The panel said something a bit different–don’t waste your time if the DOSE IS TOO LOW. Will have to get the original article. But it seems to be a tiresome misrepresentation of the data. At least, for those who read the article, they do note first —

“400 IU of vitamin D3 combined with 1,000 mg of calcium carbonate has no effect” BUT then —

“daily intake of 600 IU for vitamin D and 1,200 mg of calcium for women ages 51 to 70 had a clearer net benefit in fracture prevention.

Last month, the USPSTF finding that vitamin D supplements reduce the risk of falls in community-dwelling older people who may be prone to falling.”

Acquiring enough calcium from a healthy diet, getting enough sun and resistance exercise are all the BASIC elements of sustaining good bone health. Supplements have their place for many people. But the media distortions do not help people to make the best decision, especially when they outright distort the recommendation. And indeed many, many people are very low in Vitamin D–as we have discussed frequently here!

 

Tenofovir (Viread, Atripla) and Severe Bone Loss

Sean Strub, founder of POZ, notes on his blog the evidence for severe osteopenia or osteoporosis arising from the use of this drug. And unfortunately, from his own personal experience.

The comprehensive issues arising from ARV clearly require more diligence from physicians HEARING what people using these meds are experiencing, and acting more aggressively to mitigate the problems. This can include encouraging (prescribing??) resistance exercise, use of appropriate mineral supplements and extra Vitamin D.

One case study is reported here–we’re beginning to investigate the issue more closely.
Brim NM, Cu-Uvin S, Hu SL, O’Bell JW. Bone disease and pathologic fractures in a patient with tenofovir-induced Fanconi syndrome. AIDS Read. 2007 Jun;17(6):322-8, C3.
Comment in: * AIDS Read. 2007 Jun;17(6):326-7.

We report the case of an HIV-positive patient with preexisting bone disease who developed tenofovir-induced Fanconi syndrome and subsequently sustained pathologic fractures. We suggest that tenofovir treatment may have contributed to the patient’s pathologic fractures through its effects on phosphorus balance and vitamin D metabolism. This case highlights the importance of monitoring not only for renal impairment but also for bone disease in patients receiving tenofovir treatment, especially given the high prevalence of osteopenia and osteoporosis in HIV-positive patients.

Recommendations from the Vitamin D Council

The Vitamin D Council is a California non-profit that promotes education about the health benefits of Vitamin D, and advocates for wider use of supplementation, at a much higher dose than the current RDA, to ward off a variety of diseases, including several types of cancer, diabetes, and cardiovascular disease.

Here are some highlights from the Council’s home page, as accessed by us 10/22/2009:

Current research has implicated vitamin D deficiency as a major factor in the pathology of at least 17 varieties of cancer as well as heart disease, stroke, hypertension, autoimmune diseases, diabetes, depression, chronic pain, osteoarthritis, osteoporosis, muscle weakness, muscle wasting, birth defects, periodontal disease, and more.

Vitamin D’s influence on key biological functions vital to one’s health and well-being mandates that vitamin D no longer be ignored by the health care industry nor by individuals striving to achieve and maintain a greater state of health.
…
Sunshine and Your Health

If well adults and adolescents regularly avoid sunlight exposure, research indicates a necessity to supplement with at least 5,000 units (IU) of vitamin D daily. To obtain this amount from milk one would need to consume 50 glasses. With a multivitamin more than 10 tablets would be necessary. Neither is advisable.

The skin produces approximately 10,000 IU vitamin D in response 20–30 minutes summer sun exposure—50 times more than the US government’s recommendation of 200 IU per day!

On this website, we also noted with interest a letter from a Wisconsin doctor/long-term care facility manager on the apparent protective value of Vitamin D during a spike in the state’s swine flu rate in June 2009. The doctor had mandated Vitamin D supplementation for the long-term care facility’s residents, whereas staff at the facility were under no such requirement. During the June swine flu peak, less than 1% of the facility residents developed swine flu, while at least 7% of the staff did–a significant variation in outcomes.

We’ll stay tuned to the Vitamin D Council’s website, which seems to us a useful clearinghouse of information on a supplement that holds a great deal of promise, if we’re to judge by the flood of positive new research results coming out in just the past few years. On the practical side, we also note that Vitamin D supplementation is inexpensive; that blood levels of the vitamin are easily monitored; and that overdose is rare (though we certainly recommend checking with your doctor if you plan to supplement at the levels advocated by the Vitamin D Council).

SEE ALSO THE NYBC ENTRY:

D3 – 2500IU (This format provides a convenient way to supplement for those wishing to follow the recommendations of the Vitamin D Council; other strengths are also available at NYBC.)

Vitamin D3 supplementation for people with HIV

The annual Conference on Retroviruses and Opportunistic Infections (CROI), which provides a forum for recent HIV/AIDS research, included an interesting study on Vitamin D3 supplementation.

The investigation checked Vitamin D levels in a group of NYC people with HIV (deficiency in this key nutrient having been frequently documented in other recent research), then followed them as they supplemented with D3 and calcium citrate. Different doses were given to those with severe deficiency (2800 IU/day), substantial deficiency (1800 IU/day), and mild-moderate deficiency (800 IU/day). The investigators concluded that “many HIV patients can achieve optimal vitamin D status by using oral V[itamin] D3.”

Note that, while the very high daily doses of Vitamin D3 (2800 IU/day is 14 times the current recommended dose) were deemed “safe” in the conclusion of this study, certainly anyone starting such high dose supplementatiion should do so under medical supervision.

Overall, we believe the study gives encouragement to the idea that through inexpensive supplementation, many people with HIV could improve their Vitamin D3 status and thus potentially benefit their health over the long term. Health benefits of optimal Vitamin D3 status include: lower levels of inflammation and associated health problems; lower risk of developing osteopenia/osteoporosis (a special concern for people with HIV, according to several studies from the last few years).

For further rinformation, see the NYBC entry on Vitamin D3. NYBC also stocks Jarrow’s Bone-Up supplement, which includes D3, calcium, and other nutrients to support bone health.

High Frequency of Vitamin D Deficiency in People with HIV

A number of reports in recent years have suggested an increased prevalence of osteopenia and osteoporosis (moderate and severe bone loss) in HIV-infected patients. In 2008, moreover, a study in the Journal of Clinical Endocrinology & Metabolism reported a higher rate of fractures in HIV-infected individuals compared with uninfected individuals. So there is reason for concern that osteoporosis and osteoporotic fractures will become major health problems for people with HIV as they age.

Here, we’re reporting on another study, released at the start of 2009, which fills in more pieces of information about bone health in people with HIV–and also provides guidance on supplementation strategies that could counteract bone loss and increased bone fracture rates associated with HIV. This research looked at fairly healthy (“ambulatory”) people with HIV visiting a Boston clinic in mid-winter and early spring months, and found a high frequency of vitamin D deficiency. Further tests linked this deficiency to a diminished ability to absorb and use calcium, the central ingredient in bone mass.

Based on their study, the investigators suggested that many people with HIV could benefit from daily vitamin D intake of at least 700-800 IU taken with 1200-1500mg of calcium, especially during the winter months, when the body does not have the opportunity to produce Vitamin D from exposure to sunlight.

Our conclusion: studies are now filling in the details that allow us to conclude that osteoporosis and osteoporosis-related fractures may become an increasingly important health concern for people with HIV as they age. However, there is also growing evidence that supplementing with Vitamin D and calcium can reduce this risk to bone health. It’s therefore important for people with HIV to check their multivitamin to see if they are getting appropriate levels of these two nutrients, or add a specific Vitamin D – Calcium supplement to their diet.

NOTE: NYBC stocks Vitamin D3 (the form most readily used by the body) and Calcium Blend (a food-based vegetarian supplement which includes Vitamin D3). Also available: Bone Up (Jarrow), a supplement containing calcium, Vitamin D and other components specifically for bone health.

Reference: M. Rodriguez, B. Daniels, S. Gunawardene, and G.K. Robbins. High Frequency of Vitamin D Deficiency in Ambulatory HIV-Positive Patients. AIDS RESEARCH AND HUMAN RETROVIRUSES, Vol 25, 1, 2009.

Maintaining bone health – recommendations for Calcium and Vitamin D3 supplementation

Calcium and Vitamin D are both important for keeping bones healthy. Calcium is needed by the body every day, and if not enough is taken in, then calcium is lost from the bones. Meanwhile, in order to absorb calcium effectively, the body needs Vitamin D3. So these two nutrients are both necessary, on a very regular basis, for the long-term maintenance of bone health and the prevention of such conditions as osteopenia and osteoporosis.

Recently, there has also been a lot of research and discussion about the optimum intake of Vitamin D3 to maintain bone health. Many investigators now believe that a minimum of 700 to 800 IU of vitamin D3 per day is needed by adults. This is approximately double the daily intake of 400mg that was commonly recommended in the past.

Other lines of recent research have pointed to supplementation with calcium and Vitamin D3 as having benefits in reducing risk of cancer in some populations; and there is also much study now being devoted to Vitamin D3’s role in the health of the immune system. So the old “sunshine vitamin” is definitely one to watch!

References:

Vieth R, Bischoff-Ferrari H, Boucher BJ, et al. The urgent need to recommend an intake of vitamin D that is effective. American Journal of Clinical Nutrition 2007 Mar;85:649-50.

Lappe JM, Travers-Gustafson D, Davies KM, et al. Vitamin D and calcium supplementation reduces cancer risk: results of a randomized trial. AmericanJournal of Clinical Nutrition 2007 Jun;85(6):1586-91.

For special concerns regarding HIV and bone loss, see the CATIE treatment update “Complications and Side Effects – Calcium and Vitamin D”.

For some recommendations on supplementation from NYBC, see the section “Better Bones”.

Vitamin D3 makes a guest appearance on Martha Stewart (with help from Dr Andrew Weill)

Hope we won’t be regarded as too frivolous if we admit that yesterday evening we turned to our TIVO and took in the day’s Martha Stewart Show, which featured nutrition and integrative medicine guru Dr Andrew Weill. What struck us most about Dr. Weill’s segment was his answer to a question from a female audience member on strategies for preventing osteoporosis. Dr. Weill’s answer: women should start supplementing with calcium and Vitamin D3 by the time they leave adolescence. The benefits to bone health of calcium plus D3, and–just as significantly–new findings on Vitamin D3’s role in reducing cancer rates, are now so well documented that this supplement regimen has become a “no-brainer” even for younger women.

It was nice to see a current view on D3 presented so clearly to a mass audience. (Although we have put some effort into finding and interpreting the latest news on this very interesting vitamin, we are quite aware that this Blog does not reach a public of millions!)  But we also reflected, once more, that the new evidence about Vitamin D3 also ought to be of special interest to people with HIV.  As highlighted in the media earlier this month, many people with HIV who are entering middle age are facing health issues such as osteoporosis and cancers that are more usually associated with later life. And while there has not been so much research specifically on HIV and D3, the science may already be compelling enough to make this supplement a priority in regimens.  After all, we are talking about a very low-cost supplement with negligible risks of side effect. If the results of such supplementation are reduced osteoporosis and reduced cancer risk in people with HIV as they grow older, then it might just be time to take a cue from Martha Stewart and her guest Dr Weill…

Osteoporosis in People with HIV – Info Sheet from aidsmap.com

As a number of recent news reports have highlighted, osteoporosis can be a health concern for people with HIV, so we’d like to draw your attention to the information sheet presented on the website aidsmap.com, which is sponsored by the leading HIV health information nonprofit in Britain.
Below are some excerpts from the online information sheet:

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Why does osteoporosis occur in people with HIV?
Osteoporosis is caused by a lack of bone calcium and protein, but the reasons for its appearance in relatively young, HIV-positive people, is still unexplained.
The high prevalence of osteopenia in HIV-positive people relative to HIV-negative people suggests that HIV itself contributes to thinning bones in this population (Knobel 2001; McGown 2001; Negredo 2001). However, it is not yet clear whether other factors contribute to thinning bones in HIV-positive people. There is growing evidence that protease inhibitors are not associated with osteoporosis but other antiretrovirals may contribute to this condition.
…
Link to protease inhibitors and metabolic disorders?
Several studies have found that protease inhibitor (PI) treatment has been associated with a significantly greater incidence of osteoporosis.
For example, one study found that 21% of a group of 64 men receiving PIs, compared with 6% of an age-matched HIV-negative control group, had severe osteoporosis. There was no significant relationship between osteoporosis and fat redistribution (Tebas 2000). Fifty percent of the PI group had some evidence of reduced bone mass, compared to 29% of the control group. Although some researchers have speculated that reduced level of the male sex hormone testosterone might be linked to reduced bone mass, no link was found in this study.
Treatment of osteoporosis
…
In a recent presentation, one of the leading researchers on osteoporosis in HIV suggested that the only interventions currently supported by evidence are to ensure an adequate calcium intake (approximately 1500mg per day), and to ensure a vitamin D intake of between 400 and 1000IU per day.

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You can read the complete aidsmap.com information sheet on osteoporosis in people with HIV at:

http://www.aidsmap.com/cms1032619.asp