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Venous Insufficiency: El Paso Back Clinic

Venous Insufficiency: El Paso Back Clinic

by | Integrative Functional Wellness, Massage

Arteries carry blood from the heart to the rest of the body. The veins transport blood back to the heart, and the valves in the veins stop the blood from flowing backward. When the veins have difficulties sending blood from the limbs back to the heart, this is known as venous insufficiency. With this condition, the blood does not flow back properly to the heart, causing blood to accumulate in the veins of the legs. Chiropractic care, therapeutic massage, and functional medicine can increase and improve circulation and help manage symptoms.

Venous Insufficiency: EP Chiropractic Functional Medicine Clinic

Venous Insufficiency

The circulatory system is responsible for transporting blood, oxygen, and nutrients to the cells in the body. This system consists of the heart, arteries, veins, and capillaries. When blood circulation is restricted, it can lead to a buildup of toxins and waste products, which can cause various health problems, including fatigue, muscle cramps, and dizziness. Unhealthy circulation can also contribute to other health conditions like heart disease, stroke, and diabetes. The most common causes of venous insufficiency include:

  • Blood clots
  • Varicose veins
  • A family history of venous insufficiency.
  • Deep vein thrombosis.
  • When forward flow through the veins is obstructed, such as in the case of a blood clot, blood builds up below the clot, which can lead to venous insufficiency.
  • In varicose veins, the valves can be missing or damaged, and blood leaks back through the defective valves.
  • In some cases, weakness in the leg muscles that push blood forward can also contribute to venous insufficiency.
  • Venous insufficiency is more common in women than men and is more likely in adults over 50.

Circulation Symptoms

There are different symptoms associated with unhealthy circulation, and can include:

  • Tingling or numbness in the extremities
  • Cold hands and feet
  • Pain or cramping in the muscles
  • Weakness or fatigue
  • Dizziness or lightheadedness
  • Nausea
  • Shortness of breath
  • Erectile dysfunction

Symptoms of venous insufficiency include:

  • Swelling of the legs or ankles – edema
  • Pain that gets worse when standing and improves when raising the legs.
  • Aching, throbbing, or a feeling of heaviness in the legs.
  • A sense of tightness in the calves.
  • Leg cramps
  • Weak legs
  • Itchy legs
  • Thickening of the skin on the legs or ankles.
  • Skin that is changing color, especially around the ankles
  • Varicose veins
  • Leg ulcers

Diagnosis

A doctor will perform a physical examination and take a complete medical history. They may order imaging tests to locate the source of the problem. These tests may include a venogram or a duplex ultrasound.

Venogram

  • A doctor will insert an intravenous contrast dye into the veins.
  • Contrast dye causes the blood vessels to appear opaque on the X-ray image, which helps the doctor see them on the image.
  • This dye will give the doctor a clear image of the blood vessels.

Duplex Ultrasound

  • A duplex ultrasound tests the speed and direction of blood circulation in the veins.
  • A technician will place gel on the skin and press a small hand-held instrument on and around the area.
  • The instrument uses sound waves that bounce back to a computer and produce images of blood circulation.

Treatment

Treatment will depend on various factors, including the reason for the condition and individual health status and history. Other factors a doctor will consider include:

  • Specific symptoms
  • Age
  • The severity of the condition
  • Medication and/or procedure tolerance

The most common treatment is prescription compression stockings.

  • These special stockings apply pressure on the ankle and lower leg.
  • They help improve blood circulation and reduce leg swelling.
  • Compression stockings come in a range of prescription strengths and lengths.

Strategies

Treatments can include several methods.

Improving Circulation

Chiropractic adjustments and vascular massage therapy on the legs can help improve blood circulation. Massage therapies such as vascular and lymphatic drainage massages aim to increase circulation, improve tissue nutrition, and can benefit patients with varicose veins and chronic venous insufficiency.

  • The technique for lymphatic drainage involves light strokes to move lymph fluid into lymph vessels.
  • The technique used to improve circulation involves short strokes to move blood from the valves to the veins.

However, massage therapy is not for all patients with vein diseases and conditions.

  • Massage therapy is not recommended for patients with advanced-stage vein disease, in which large and bulging veins, ulcerations, and discoloration are present.
  • Massaging the area could cause the weakened veins to burst, worsening the condition.
  • Massage therapy is also unsafe for patients with deep vein thrombosis (DVT), as it could dislodge a clot and cause it to travel.

Medications

Medications may be prescribed. These include:

  • Diuretics – medications that draw extra fluid from the body and are excreted through the kidneys.
  • Anticoagulants – medicines that thin the blood.
  • Pentoxifylline – medicine that helps improve blood circulation.

Surgery

More serious cases may require surgery. A doctor may suggest one of the following surgical procedures:

  • Surgical repair of the veins or valves.
  • Removing the damaged vein.
  • Minimally invasive endoscopic surgery – The surgeon inserts a thin tube with a camera to see and tie off damaged veins.
  • Laser surgery – A treatment that uses laser light to fade or close off damaged veins.
  • Vein bypass – A healthy vein is transplanted from a different body area. Generally used only in the upper thigh and as a last option for severe cases.

Venous Insufficiency: What You Need To Know

References

Annamaraju P, Baradhi KM. Pentoxifylline. [Updated 2022 Sep 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559096/

Chronic venous insufficiency. (n.d.). hopkinsmedicine.org/healthlibrary/conditions/cardiovascular_diseases/chronic_venous_insufficiency_85,P08250/

Evrard-Bras, M et al. “Drainage lymphatique manuel” [Manual lymphatic drainage]. La Revue du praticien vol. 50,11 (2000): 1199-203.

FIELDS, A. “Leg cramps.” California medicine vol. 92,3 (1960): 204-6.

Felty, Cindy L, and Thom W Rooke. “Compression therapy for chronic venous insufficiency.” Seminars in vascular surgery vol. 18,1 (2005): 36-40. doi:10.1053/j.semvascsurg.2004.12.010

Mayo Clinic Staff. (2017). Varicose veins.mayoclinic.org/diseases-conditions/varicose-veins/diagnosis-treatment/drc-20350649

Patel SK, Surowiec SM. Venous Insufficiency. [Updated 2022 Aug 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430975/

Youn, Young Jin, and Juyong Lee. “Chronic venous insufficiency and varicose veins of the lower extremities.” The Korean journal of internal medicine vol. 34,2 (2019): 269-283. doi:10.3904/kjim.2018.230

Anti-Inflammatory Diets: Back Clinic Chiropractic Nutrition

Anti-Inflammatory Diets: Back Clinic Chiropractic Nutrition

by | Diets, Functional Medicine

Around 60% of individuals have a condition caused by or complicated by chronic inflammation. The body reacts with acute inflammation, which is beneficial as the immune system fights off bacteria that could infect the injury. Examples could be getting a cut on the finger that swells for a day or so to repair the wound or catching a cold and coughing up mucus to expel the germs. However, acute inflammation only lasts as long as necessary; chronic inflammation can last for weeks, months, and years. Individuals can have chronic inflammation and not know the damage being done to arteries and organs until pain or other issues begin to present. There are a few anti-inflammatory diets, which are nutrition plans that can help reduce inflammation.

Anti-Inflammatory Diets Chiropractic Nutrition

Anti-Inflammatory Diets

Health-promoting substances include vitamins, minerals, fiber, omega-3 fatty acids, flavan-3-ols in tea and cocoa, and anthocyanins in blueberries, strawberries, raspberries, and other red and purple plant foods. Certain chemicals in the body cause inflammation, and naturally-occurring chemicals in foods, can prevent and combat inflammation by providing essential nutrients.

Nordic Diet

This includes Denmark, Sweden, and Finland, which each have different cuisines, but traditionally, they share healthy foods that provide anti-inflammatory benefits, including:

  • Apples
  • Berries
  • Broccoli
  • Cabbage
  • Carrots
  • Canola oil is the principal oil
  • Fish
  • Pears
  • Potatoes
  • Sauerkraut
  • Whole rye

Rye is a grain shown to help reduce blood sugar, the inflammatory marker C-reactive protein. Individuals that follow this way of eating have lower blood levels of C-reactive protein and other inflammation markers. A randomized study was done in various Nordic countries and lasted six to 24 weeks. One group was assigned a healthy Nordic diet while the other stayed on the country’s modern, less healthy diet. The studies found that individuals that practiced a healthy Nordic diet even for a short while improved inflammatory markers and lost weight.

Mexican Diet

Research has linked a traditional Mexican diet to lower inflammation. Staple foods of a traditional Mexican diet include:

  • Cheese
  • Corn tortillas
  • Fruits and vegetables, including hot peppers
  • Rice – brown and white
  • Legumes/Beans

Legumes/beans are linked to protection from inflammatory-related conditions that include:

  • Obesity
  • High blood pressure
  • High blood cholesterol
  • Type 2 diabetes
  • Cardiovascular disease

Legumes are high in fiber, which helps:

 A National Cancer Institute study of post-menopausal women of Mexican descent living in the U.S. found that those following a more traditional Mexican diet averaged 23% lower C-reactive protein levels.

Nutritionist Health Coach and Chiropractic

In some instances, chronic inflammation can come from acute inflammation that does not turn off, which can happen when the body does not make enough chemical substances responsible for turning off the immune response. Blood tests for inflammation can include tests that detect the C-reactive protein and the erythrocyte sedimentation rate, which measures the speed red blood cells settle in a test tube that shows if more inflammatory compounds are present. A combined approach and team of medical professionals, including chiropractic, massage therapy, health coaching, and nutrition, can help relieve and prevent inflammation.

Nutritionist

  • Consulting a nutritionist is recommended to figure out and determine the best diet/nutrition plan for the individual.
  • A nutritionist may also suggest supplementation like vitamin D, magnesium, and fish oil supplements.
  • Body composition analysis breaks down the body elements of water, protein, minerals, and fat that can also discover inflammation markers.

Chiropractic

Chiropractic adjustments help reduce the production of cytokines or proteins that regulate the cells of the immune system. Overproduction of cytokines can cause a severe inflammatory response. Chiropractic’s purpose is to rebalance the body by realigning the vertebrae to reduce pressure on the nerves and promote a healthy nervous system. When the spine and other joints are correctly aligned, the nerves function correctly, returning the body’s biomechanics to normal.

InBody Results

References

Galbete C, Kröger J, Jannasch F, et al. Nordic diet, Mediterranean diet, and the risk of chronic diseases: the EPIC-Potsdam study. BMC Med. 2018;16(1):99.

Lankinen M, Uusitupa M, Schwab U. Nordic Diet and Inflammation-A Review of Observational and Intervention Studies. Nutrients. 2019;11(6):1369.

Ricker MA, Haas WC. Anti-Inflammatory Diet in Clinical Practice: A Review. Nutrition in Clinical Practice. 2017;32(3):318-325.

Santiago-Torres M, Tinker LF, Allison MA, et al. Development and Use of a Traditional Mexican Diet Score in Relation to Systemic Inflammation and Insulin Resistance among Women of Mexican Descent. J Nutr. 2015;145(12):2732-2740.

Valerino-Perea, Selene, et al. “Definition of the Traditional Mexican Diet and Its Role in Health: A Systematic Review.” Nutrients vol. 11,11 2803. 17 Nov. 2019, doi:10.3390/nu11112803

Yang, Yoon Jung, et al. “Dietary flavan-3-ols intake and metabolic syndrome risk in Korean adults.” Nutrition research and practice vol. 6,1 (2012): 68-77. doi:10.4162/nrp.2012.6.1.68

The Atlas Vertebra Key To Maintaining Head Balance And Alignment

The Atlas Vertebra Key To Maintaining Head Balance And Alignment

by | Headaches & Treatments, Neck Pain

The Atlas vertebra is named for the mythological figure who held the world on their back/neck. The vertebrae are located at the top of the spine, where the cranium and spine connect. More than just a foundation for support, the vertebrae could be the most important vertebrae of the body. It consists of a complex bundle of nerves, vertebral arteries, and is the point where the entire weight of the cranium makes contact.  
 
The myth requires Atlas to be careful while holding the world carefully and confidently at all times, otherwise it will come crashing down. The key is being able to balance it perfectly. The vertebra has the same job to hold the head up properly and maintain posture. If not problems with balance and alignment will begin to develop, and affect the entire spine.  
11860 Vista Del Sol, Ste. 128 The Atlas Vertebra Key To Maintaining Head Balance And Alignment
 

The Atlas Vertebra

 

Balance

The Atlas vertebrae’s role in maintaining balance is based on its ability to adjust to the weight of the head. The actual vertebra is wider than the other cervical vertebrae. This creates a center of gravity that is reinforced through proper posture. It distributes the weight of the head (10-12lb) evenly to centralize the weight and is supported by the natural curvature of the spine. If the center of gravity shifts, the Atlas vertebra will tilt in that direction as well. This creates instability in the cervical spine and can increase the amount of weight the spine is taking and trying to redistribute. This creates spinal issues and leads to everything from poor posture, overcompensation that leads to injury.  

Shifting Causes

Disruption to the vertebra and its ability to balance can come from a variety of causes and can occur as a result of chronic and acute conditions. Some include:
  • Auto accidents, sports, work injuries can cause cervical soft tissue damage
  • Dislocation of cervical vertebrae below the Atlas results in instability
  • Poor posture/s make individuals overcompensate to one side of the body straining muscles, ligaments, tendons causing pain and other issues
  • Herniated, bulging, and slipped discs
11860 Vista Del Sol, Ste. 128 The Atlas Vertebra Key To Maintaining Head Balance And Alignment
 

Unbalanced effects

Spinal issues range from simple neck pain and soreness to full-on chronic pain. Because the Atlas can alter the balance of the entire spine, combined with cranium support, issues can be localized and referred creating further complications. Addressing the root problems requires a comprehensive chiropractic approach. Chiropractic will assess the position of the spine and determine the degree to which Atlas has shifted out of place. An adjustment treatment plan makes it possible to undo the widespread damage.

Body Composition

 

Muscle Loss

Individuals do not realize that muscle loss occurs throughout their lifetime. This is because muscles, like other tissues in the body, must go through cell turnover and protein synthesis. This means that the body is constantly breaking down protein in the muscles and rebuilding them. Skeletal muscle can be developed with proper nutrition and includes consuming a proper amount of protein to provide the necessary amino acids and from physical activity. The reverse is also true, if an individual becomes less physically active and/or their diet no longer supports the development of increased muscle tissue, the body enters a catabolic/tissue-reducing state known as muscle atrophy.

Dr. Alex Jimenez�s Blog Post Disclaimer

The scope of our information is limited to chiropractic, musculoskeletal, physical medicines, wellness, and sensitive health issues and/or functional medicine articles, topics, and discussions. We use functional health & wellness protocols to treat and support care for injuries or disorders of the musculoskeletal system. Our posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate and support directly or indirectly our clinical scope of practice.* Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We also make copies of supporting research studies available to the board and or the public upon request. We understand that we cover matters that require an additional explanation as to how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900. The provider(s) Licensed in Texas& New Mexico*
References
Woodfield, H Charles 3rd et al. �Craniocervical chiropractic procedures – a pr�cis of upper cervical chiropractic.��The Journal of the Canadian Chiropractic Association�vol. 59,2 (2015): 173-92.
Nutritional Strategies For Skeletal And Cardiovascular Health

Nutritional Strategies For Skeletal And Cardiovascular Health

by | Functional Medicine, Nutrition

Nutritional Strategies:� Hard Bones, Soft Arteries, Rather Than Vice Versa

ABSTRACT

nutritional strategiesNutritional Strategies: The focus of this paper is to explore better strategies for optimizing bone strength and reducing risk of fracture, while at the same time decreasing risk of cardiovascular disease. The majority of Americans do not consume the current recommended dietary allowance for calcium, and the lifetime risk of osteoporosis is about 50%. However, traditional mono-nutrient calcium supplements may not be ideal. We comprehensively and systematically reviewed the scientific literature in order to determine the optimal dietary nutritional strategies and nutritional supplements for long- term skeletal health and cardiovascular health. To summarize, the following steps may be helpful for building strong bones while maintaining soft and supple arteries: (1) calcium is best obtained from dietary sources rather than supplements; (2) ensure that adequate animal protein intake is coupled with calcium intake of 1000 mg/day; (3) maintain vitamin D levels in the normal range; (4) increase intake of fruits and vegetables to alkalinize the system and promote bone health; (5) concomitantly increase potassium consumption while reducing sodium intake; (6) consider increasing the intake of foods rich in vitamins K1 and K2; (7) consider including bones in the diet; they are a rich source of calcium-hydroxyapatite and many other nutrients needed for building bone.

INTRODUCTION: Nutritional Strategies

Calcium: General Physiology Andepidemiology

Calcium is the most ubiquitous mineral in the human body. An average-sized adult body contains approximately 1000 to 1200 g of calcium, which is predominately incorporated into bones and teeth in the form of calcium-hydroxyapatite (Ca10(PO4)6(OH)2) crystals. The remainder circulates throughout the blood and soft tissues, and plays fundamental roles in cell conduction, muscle function, hormone regulation, vitamin (Vit) K-dependent pathways, and cardiac and blood vessel function.1

Some studies indicate only 30% of the US population consumes the Recommended

Dietary Allowance of calcium, which is 1000� 1200 mg daily.1 Furthermore, humans absorb only about 30% of calcium from foods depend- ing on the specific source.1 The body will demineralize its own skeletal system to maintain serum calcium levels in situations where dietary calcium is insufficient and/or absorption is decreased, and/or excretion is increased.2

Osteopenia/Osteoporosis:�An Epidemic

Starting at about age 50 years, postmenopausal women lose about 0.7�2% of their bone mass each year, while men over age 50 years lose 0.5�0.7% yearly. Between ages 45 and 75years, women, on average, lose 30% of their bone mass, whereas men lose 15%.

According to the US Surgeon General�s Report, 1 in 2 Americans over age 50 years is expected to have or to be at risk of develop- ing osteoporosis.3 Osteoporosis causes 8.9 million fractures annually, with an estimated cumulative cost of incident fractures predicted at US$474 billion over the next�20 years in the USA.3�6 Among adult women over age 45 years, osteoporosis accounts for more days spent in hospital than many other diseases such as diabetes, myocardial infarction (MI), chronic obstructive airway disease and breast cancer.3 Fragility fractures are the primary cause of hospitalization and/or death for US adults ? age 65 years and older; and 44% of nursing home admissions are due to fractures.3

A Mayo Clinic study reported that compared to 30 years ago, forearm fractures have risen more than 32% in boys and 56% in girls. The authors concluded that dietary changes, including insufficient calcium and excess phosphate, were significantly associated with increased fractures.7 Public health approaches are crucial to prevent symptomatic bone disease, but widespread pharmacological prophylaxis is prohibitively expensive and carries potential serious adverse effects.

Cardiovascular Disease & Bone Mineral Disease: A Calcium Nexus

Strong epidemiological associations exist between decreased bone mineral density (BMD) and increased risk of both cardiovascular (CV) disease and CV death.8 For example, individuals with osteoporosis have a higher risk of coronary artery disease, and vice versa. This problem will be magnified if the therapies for osteoporosis (eg, calcium supplements) independently increase risk of MI.

Issues With Dairy As Primary Source Of Calcium

Dairy foods and beverages account for about 70% of all dietary calcium intake among Americans. Dozens of epidemiological and randomized controlled trials in adults and children have used dairy products as the principal source of calcium, and have credited dairy intake with preventive benefits on study end points including bone mass, fractures and osteoporosis. A recent meta-analysis of over 270 000 people showed a strong trend for dairy intake protecting against hip fracture; the relative risk (RR) of hip fracture per daily glass of milk was 0.91, 95% CI 0.81 to 1.01.9

In many industrialized nations, milk is often the most cost-effective strategy for achieving recommended levels of calcium intake at a population level. Yet, legitimate concerns exist regarding potential deleterious effects of chronic dairy intake on health.10�16 Dairy foods, on an evolutionary time scale, are relative �new-comers� to the hominin diet.17 Domestication of cattle, sheep and goats first occurred approximately 11 000�10 000 years Before Present.17 Furthermore, it appears that an estimated 65% of the worldwide population expresses the phenotype of lactase non-persistence.18

Consumption of cow�s milk has been inconsistently associated with cataracts, ovarian and prostate cancers, and Parkinson�s disease, and it has been implicated in certain autoimmune diseases, such as type 1 diabetes and multiple sclerosis. Overall, the evidence for dairy-induced human disease appears to be most consistent for prostate cancer and for type 1 diabetes.19

A recent study of over 106 000 adults followed for 20 years showed that drinking three or more glasses of milk per day was associated with increased risks for bone fracture and higher mortality rates compared with drink- ing not more than one glass of milk per day.20 By contrast, for the women in that study, each daily serving of cheese and/or other fermented milk products such as yogurt was associated with a 10�15% decrease in the rates of mortality and hip fractures (p<0.001). However, this was an observational study with inherent limitations such as residual confounding and reverse causation, and thus, firm conclusions cannot be drawn from the data.

The sugar in milk, lactose, is broken down in the gastrointestinal tract to d-galactose and d-glucose. d-Galactose has been found to increase inflammation and oxidation in adult humans, and in adult animals this sugar triggers accelerated aging, neurodegeneration, and a shortened life span.20

Thus, cow�s milk, though rich in many nutrients, including calcium, has issues that render it less than ideal as a dietary staple for many adults. On the contrary, fermented dairy foods, such as yogurt and cheese, appear to be safer than milk, possibly because the most or all of d-galactose has been metabolized by bacteria.20

Plant-Based Dietary Sources Of Calcium & Protein: Effects On Bone Health

nutritional strategiesMost vegetarians, especially vegans, appear to absorb less calcium because of the oxalic and phytic acid contained in many plant, grain and legume products.1 Indeed, several studies have reported that risks of bone fracture are higher in vegans�likely due, at least in part, to their lower dietary calcium intake, and/or poor absorption of this key mineral (table 1).21

Dietary Protein, Calcium And Bone Health

Evolutionary evidence suggests that preagricultural diets were net base-yielding, and contributed to the robust�bone health generally seen among hunter-gatherers.10 17�By contrast, processed foods displace base-yielding fruits�and vegetables, thereby shifting to a net acid-yielding diet.2 22�24�

Increased protein intake can raise levels of insulin-like growth factor 1, which is anabolic, and contributes to bone building. Experts currently agree that diets moderate in protein (?1.0�1.5 g/kg/day) are associated with normal calcium metabolism, and do not adversely alter bone metabolism; however, at lower protein intakes (<0.8 g/kg/day), intestinal calcium absorption is reduced and levels of parathyroid hormone rise, causing the mobilization of calcium from bone.25 26

 

A growing body of evidence indicates that diets higher in animal protein associate with greater bone mass and fewer fractures, particularly if the calcium intake is also sufficient (approximately 1000 mg of calcium/day) (figure 1).26�28 Thus, a diet providing ample dietary calcium, along with alkalizing nutrients, such as fruits and vegetables, and possibly also alkaline mineral waters, may create a milieu where moderate intake of animal protein contributes favorably to bone health. Additionally, intake of protein plus calcium with Vitamin D may reduce fracture rates through mechanisms independent of bone density.29

nutritional strategies

Magnesium

nutritional strategiesMaintaining replete magnesium status may reduce risk for the metabolic syndrome, diabetes, hypertension and MI.30 Circumstantial and experimental evidence has also implicated magnesium deficiency in osteoporosis.31�34 Optimal dietary magnesium intake is about 7�10 mg/ kg/day, preferably in the context of a net base-yielding diet, since a net acid-yielding diet increases excretion of both magnesium and calcium (table 2).

Potassium/Sodium Ratio Affects Calcium Metabolism

A potassium/sodium ratio of 1.0 or higher is associated with a 50% lower risk of CVD and total mortality com- pared with a ratio under 1.0.35 Reducing excessive sodium intake is also associated with resultant decreased urinary calcium excretion, which may help to prevent against bone demineralization.36 The average potassium content (about 2600 mg/day) of the typical US diet is substantially lower than its sodium content (about 3300 mg/day).35 Approximately 77% of dietary sodium chloride is consumed in the form of processed foods. By contrast, potassium is naturally abundant in many unprocessed foods, especially vegetables, fruits, tubers, nuts, legumes, fish and seafood. In fact, a high potassium/sodium ratio is a reliable marker for high intake of plant foods and lower intake of processed foods.35 High dietary sodium intake has been associated with endothelial damage, arterial stiffness, decreased nitric�oxide production and increased levels of transforming growth factor ?; whereas, high potassium dietary intake can counteract these effects.35 36

Evidence indicates that the lowest CV event rates occur in the moderate sodium excretion and high potassium excretion groups.37 Thus, it appears that a moderate sodium diet (2800�3300 mg/day) in conjunction with a high potassium intake (>3000 mg/day) might confer the optimal CV benefits for the general population.37

Vitamin K & Bone Health

Emerging evidence suggests that Vitamin K may confer protective effects for both the skeletal and CV systems. Vitamin K operates in the context of other fat-soluble vitamins, such as A and D, all of which are involved in maintenance of serum calcium concentration, along with the manipulation of materials leading to bone morphogenesis and maintenance of bone tissue.38 Specifically, the oxidation of Vitamin K results in activation/carboxylation of matrix Gla protein (MGP) which is partially responsible for mineralizing bone.39

Also, Vit K is required for the activation (?-carboxylation) of osteocalcin; the inactivated form, or per cent of undercaboxylated-osteocalcin (%ucOC), has been found to be a sensitive indicator of Vitamin K nutrition status.38 In cross-sectional and prospective analyses, elevated %ucOC, which occurs when Vitamin K status is low, is a marker of increased risk for hip fracture in the elderly.38

Several large observational studies appear to support the benefits of Vitamin K on bone health.38 A meta-analysis concluded that while supplementation with phytonadione (Vitamin K1) improved bone health, Vitamin K2 was even more effective in this regard.40 This large and statistically rigorous meta-analysis concluded that high Vitamin K2 levels were associated with reduced vertebral fractures by approximately 60% (95% CI 0.25% to 0.65%), hip fractures by 77% (95% CI 0.12% to 0.47%), and all non- vertebral fractures by approximately 81% (95% CI 0.11% to 0.35%). Moreover, the benefit of Vitamin K on bone may not be due to its ability to increase BMD, but rather to its effects at increasing bone strength.41

Vitamin K Benefits In CV Health

Mounting evidence suggests vascular calcification whether in the coronary or peripheral arteries is a powerful predictor of CV morbidity and all-cause mortal- ity.42 Prevention of vascular calcification is therefore important as an early intervention to potentially improve long-term CV prognosis.

A major calcification inhibitory factor, is a Vitamin K-dependent protein synthesized by vascular smooth muscle cells.42 Increased

nutritional strategiesVitamin K2 intake has been associated with decreased arterial calcium deposition and the ability to reverse vascular calcification in animal models. Vitamin K2 prevents pathological calcification in soft tissues via the carboxylation of protective MGP. The undercarboxylated (inactive) species of MGP is formed during inadequate Vitamin K status, or as a result of Vitamin K�antagonists.42 Low Vitamin K status is associated with increased vascular calcifications, and can be improved by effective Vitamin K supplementation (table 3).43 44 In two different randomized, double-blind controlled trials, supplemental Vitamin K has been shown to significantly delay both the development of coronary artery calcification and the deterioration of arterial elasticity.45 46

Dietary Vitamin K exists as two major forms: phylloquinone (K1) and menaquinones (MK-n). K1, the predominant dietary form of Vitamin K, is abundant in dark-green leafy vegetables and seeds. The main dietary sources for MK-n in Western populations are fermented foods, especially natto, cheese and curds (mainly MK-8 and MK-9).47

Calcium Supplementation & Bone Health

A recent large meta-analysis of 26 randomized controlled trials reported that calcium supplements lowered the risk of any fracture by a modest but statistically significant 11% (n=58 573; RR 0.89, 95% CI 0.81 to 0.96).48 Even so, the authors concluded that the evidence for calcium supplements on bone health was weak and inconsistent.

Other large meta-analyses found that calcium supplementation was most effective for preventing hip fractures when it was combined with Vitamin D.49�51 Indeed Vitamin D plays a major role in intestinal calcium absorption and bone health (figure 2).52 Additionally, calcium absorption is, in part, dependent on adequate stomach acid, and both these parameters tend to decrease with age. Drugs that markedly reduce stomach acid, such as proton pump inhibitors, have been shown to reduce calcium absorption and increase risk of osteoporosis and fractures.53

nutritional strategies

A large meta-analysis focusing on calcium intake and fracture risk found that in women (seven prospective cohort studies=170 991 women, 2954 hip fractures), there was no association between total calcium intake and hip fracture risk (pooled RR per 300 mg total=1.01; 95% CI 0.97 to 1.05).50 In men (five prospective cohort studies= 68 606 men, 214 hip fractures), the pooled RR per 300 mg of calcium daily was 0.92 (95% CI 0.82 to 1.03).

Monosupplementation with calcium, especially using the most commonly prescribed formulations (calcium carbonate and calcium citrate) might drive down the absorption of phosphate, thereby contributing to bone demineralization secondary to abnormal calcium to phosphate ratios.54 The recently updated US Preventive Services Task Force (USPSTF) has stated that there is insufficient evidence that calcium and Vitamin D prevent fractures in premenopausal women or in men who have not experienced a prior fracture. Indeed, the USPSTF now recommends against daily calcium supplementation for primary prevention of fragility fractures; stating, �the balance of benefits and harms cannot be determined�.55

Calcium Supplementation & Arterial Health

The Women�s Health Initiative, a 7-year, placebo- controlled randomized trial involving 36 282 participants, found that calcium supplementation with Vitamin D�(1000 mg/400 IU daily) had a neutral effect on coronary risk and cerebrovascular risk.56 By contrast, some subsequent publications have reported data challenging the CV safety of calcium supplementation.57�60

One meta-analysis of placebo-controlled trials involving 28 000 participants reported that a daily calcium supplement was associated with an increased risk of MI (HR 1.24, 95% CI 1.07 to 1.45, p=0.004).58 A prospective study of 388229 men and women with a 12-year follow-up showed that calcium supplementation was associated with elevated risk of heart disease death in men, but not in women.61 Yet, only one randomized controlled trial of calcium supplementation using adverse cardiac events as the primary end point has been published. In that study, daily supplementation using 1200 mg of calcium carbonate did not increase the risk of CV death or hospitalization for 1460 women (mean age 75 years).62

nutritional strategies

In a prospective cohort study with a mean follow-up of 19 years, both�high and low dietary calcium intakes were associated with increased CV disease and higher all-cause mortality (figure 3).51 Importantly, a low dietary calcium intake with or without calcium supplementation is also associated with higher CV morbidity and mortality rates.51

Other possible mechanisms that have linked calcium supplements with CV disease include coronary artery calcification, impaired vasodilation, increased arterial stiffness, and hypercoagulability.51 66

Nutritional Strategies: Food As The Ideal Source Of Calcium

The traditional focus in nutritional strategies based on supplementation of single isolated nutrients may be especially mis- guided in the case of calcium and bone health. A diet supplemented with calcium as a mononutrient pill is not ideal for promoting bone health, and may instead accelerate arterial plaque growth and vascular calcification, and increase risk of MI. Food-based solutions place evidence-based emphasis on finding the admixture of foods that balance the acid�base status of the body, and that most favorably impact the body�s calcium metabolism and bone health.

A plant-rich, grain-free diet alters the acid�base status so as to be slightly alkaline, which is conducive for bone health. However, plants are relatively poor sources of calcium compared to animal sources such as dairy pro- ducts and animal bones. We suspect that milk, though an excellent source of bioavailable calcium, has potential adverse health effects for some individuals. Additionally, 65% of the world�s population show some decrease in lactase activity during adulthood. Importantly, fermented dairy has been linked to favorable outcomes for bone health and mortality risk.

Benefits Of Consuming Bones Or Bone Meal

Ethnographic and anthropological studies indicate that adult human hunter-gatherers consumed most of their calcium in the form of bones from animals, such as small and large mammals, birds, fish and reptiles.67 68 Indeed through millions of years of evolution, we are genetically adapted to consume a large proportion of our dietary calcium from bones, where calcium is absorbed along with a matrix of nutrients including magnesium, phosphorus, strontium, zinc, iron, copper, collagen protein, aminoglycans and osteocalcin�all of which also support robust bone formation.68 69 Theoretically, including animal bones (sardines, salmon, soft chicken bones, bone broths, etc) may be an effective dietary strategy to ensure adequate calcium intake and to optimize long-term bone health.

Mineral supplements made from bone meal, when taken with food, theoretically might provide a more practical means to ensure

nutritional strategiesadequate calcium intake without predisposing to CVD risk. Ingestion of micro- crystalline hydroxyapatite (the form of calcium found in bone) produces less of an acute spike in blood calcium levels compared to soluble calcium salts typically used in standard supplements, and thus may be less likely to increase vascular calcification and coronary risk.65 Hydroxyapatite also stimulates bone osteoblast cells and contains virtually all the essential building blocks needed to construct bone tissue. In a small placebo- controlled randomized trial, women who took 1000 mg of calcium in the form of hydroxyapatite in conjunction with oral Vitamin D showed a significant increase in bone thickness, whereas those who took 1000 mg of a standard calcium carbonate supplement did not (figure 4).70 Another double-blind placebo-controlled study found�that supplementing with hydroxyapatite and Vitamin D3 significantly improved serological markers of bone health.15

In theory, the addition of Vitamin K2 and magnesium to an organic bone meal supplement might further enhance its effectiveness and reduce the risk of soft tissue calcification. However, the quantity and quality of the experimental data testing the effects of Vitamin D and calcium on bone health dwarfs the data for bone meal supplementation. Much larger randomized trials will be needed to firmly establish the safety and effectiveness of bone meal as well as Vitamin K and magnesium as supplements for building bone without increasing vascular calcification.

Conclusion: Nutritional Strategies

It is becoming increasingly clear that the fundamental unit for nutrition is the food (eg, milk, nuts, eggs), not the nutrient (eg, calcium, saturated fat, cholesterol). A nutrient perceived as beneficial, such as calcium, may be unhealthy if the parent food, say milk, contains other nutrients, such as galactose, that on the balance might stimulate adverse effects in the body. In theory, consuming calcium-rich foods such as bones, fermented dairy (eg, unsweetened yogurt, kefir, cheese), leafy greens, almonds, and chia seeds may be an effective strategy for improving both calcium intake and long-term health.

James H O�Keefe,1 Nathaniel Bergman,2 Pedro Carrera-Bastos,3 Mae?lan Fontes-Villalba,3 James J DiNicolantonio,1 Loren Cordain4

 

Twitter Follow Maela?n Fontes-Villalba at @maelanfontes

Contributors NB, PC-B and MF-V assisted with the gathering and review of the data; JD, LC and JHO reviewed the data; NB, PC-B, MF-V, JD, LC and JHO assisted in the concept and design of the manuscript. JHO, NB and PC-B wrote, rewrote and finalised the manuscript.

Funding This manuscript received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. This paper was not commissioned.

Competing interests JHO is Chief Medical Officer and has an ownership interest in CardioTabs, a nutraceutical company that markets products containing vitamins and minerals.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement No additional data are available.

Open Access This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non- commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http:// creativecommons.org/licenses/by-nc/4.0/

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