CHICAGO—Despite consuming greater quantities of food than any other population on Earth, many Americans are suffering multiple nutrient deficiencies, said Steven C. Masley, MD, at the annual scientific assembly of the American Academy of Family Physicians.
Diets dense in hydrogenated fats and carbohydrates but missing key vitamins, minerals and fatty acids, lead to derangement and dysregulation of core physiology, and contribute to the epidemics of obesity, heart disease, inflammation, cancer and other chronic problems.
During his standing-room-only presentation at the AAFP meeting, Dr. Masley, a family physician and nutritionist in St. Petersburg, Fla., reviewed the most common nutrient deficiencies and strategies for improving nutritional status even in very sick individuals. In the Spring edition of Holistic Primary Care, we presented Part 1 of Dr. Masley's talk, covering fiber, long-chain fatty acids, and vitamin D (view the article by visiting www.holisticprimarycare.net and searching the keyword "Masley"). Here is the conclusion of his presentation.
To B or Not to B
More than half of all Americans are vitamin B-deficient, estimated Dr. Masley. Folic acid is the most well-known of the B vitamins, but B6 and B12 are equally important and equally deficient.
Most standard dietary recommendations call for 400 mcg of folic acid per day. "That's what all women should have before they get pregnant, not after," he noted. If one is relying solely on food to get folate, that means a glass of orange juice, two cup-sized servings of beans, a couple servings of whole grains, and 2–3 servings of leafy greens every day. "What percent of Americans are eating that? So that means that most Americans have low folate levels. Supplementing makes a ton of sense."
Spina bifida is the most obvious and grievous consequence of folate deficiency, but this nutrient is also essential in regulating inflammation, maintaining optimal neurological function, maintaining heart health and preventing cancer. "I recommend that everybody get 400–600 mcg/day of folic acid," Dr. Masley said.
If someone is folate-deficient, they're usually lacking B12 as well. The dietary deficiencies are amplified by widespread use of anti-ulcer drugs that reduce stomach acid and, consequently, reduce B12 absorption.
"B12 is dependent on acid, so when we put people on proton-pump inhibitors and don't add extra B12, we're causing B12 deficiency without even realizing it. There's nothing wrong with treating heartburn, but be aware when you give a PPI that you're decreasing B12, as well as calcium, iron and many other things. We have stomach acid for a reason, so be careful when suppressing its production."
Signs of B12 deficiency include elevated mean corpuscular volume (MCV) on a complete blood count, high homocysteine, tingling in limbs, memory loss, ataxia, and neuropathy. "If you think it's there, don't miss it. It can cause permanent, irreversible neurological damage over time."
Animal proteins are the primary dietary source, and heavy meat-eaters are probably not deficient unless they're on a PPI drug. Vegans, on the other hand, are often B12-deficient, and need to be followed carefully. "I do yearly urine methylmevalonic acid levels on my vegan patients, to ensure they're not low."
A typical multivitamin will provide about 10 mcg per day, which is not nearly enough to correct deficiencies. Otherwise healthy people on PPIs should get between 50–100 mcg of B12 per day. Vegans or people with severe deficiencies may need up to 500 mcg.
B12 shots were once popular in this country. Dr. Masley says they still have their place. "If someone is really low and showing symptoms, I will give the shots to load them up. I give 150 mcg every few weeks for a few months, until I know their loads are replenished, and then supplement (orally) with 1,000 mcg per day, especially if they have an intrinsic deficiency. B12 is very safe and very inexpensive."
Calcium: Bone "Retirement Fund"
There's a lot of attention paid to increasing calcium intake among the elderly, particularly among post-menopausal women, to avert osteoporosis. No doubt, deficiencies are extremely common in this population segment, but Dr. Masley stressed that the focus of prevention really needs to shift to the other end of the age spectrum: childhood and adolescence.
"Teenagers build their entire life's bone 'retirement fund' during that stage of life. Think of it as a calcium fund; it is like putting money in the bank. How many of you at 21 were ready to finance your retirement? Well, we build all of our bone mass by 21, and that's it. We've got to live on it the rest of our lives. So if teens don't build adequate bone mass it's a major issue," said Dr. Masley. "I think we're going to see osteoporosis rates skyrocket as the current younger generation starts hitting their 50s. It's going to be a tragedy."
How much calcium does an individual need? It depends on age and lifestyle. Standard recommendations need to be customized to individual patients. Generally it's between 800–1,500 mg/day for the "average" adult. But lifestyle is the determining factor.
Someone who regularly engages in weight-bearing exercise, walking 45 min/day, and lifting weights 2–3 times/week, who eats not more than 10 oz animal protein a day, has a relatively low salt intake, avoids phosphate-containing soft drinks, and limits coffee (tea has no effect, while coffee causes calcium loss from bones), probably needs a lot less calcium per day than someone who eats a high-meat, high-fat diet, gets little exercise and drinks a lot of soda.
The issue is the relative acidity or alkalinity of the blood. "The main reason we have all that calcium in our bones is for acid-base balance. The more alkaline the blood is, the less calcium it pulls out of bone stores, and the less a person needs to consume in order to maintain bone mineral density."
According to the World Health Organization, people living in non-industrialized parts of the world who carry their water and eat a lot of leafy greens because they're cheap, seldom get osteoporosis, despite the fact that they may get less than 500 mg/d of calcium. At the other extreme, an American who drinks a pot of coffee a day, smokes tobacco, rarely walks or exercises, and eats more than 10 oz animal protein per day will still lose bone mineral density even if they take 1,500 mg/day of calcium. In other words, one cannot really supplement one's way out of a calcium-depleting lifestyle.
"If you're in the 5% of the population that's doing everything right, 800 mg/day of calcium is plenty. If you're doing 50–75% of everything right lifestyle-wise, you need somewhere between 1,000–1,200 mg. If you already have osteopenia/osis, you need 1,500 mg per day," said Dr. Masley, though he stressed that supplementation does not obviate the need for lifestyle and dietary changes.
Food sources of calcium include dairy, soy, leafy greens and whole grains. The exceptions in the latter two categories are wheat bran, and spinach, which are high in phytate, a compound that blocks calcium absorption. Cottage cheese, that old "diet food" mainstay, is not such a great deal, calcium-wise. It is high in salt and high in animal protein, both of which promote calcium loss. "You lose as much as you gain," he noted.
Though by no means an ideal fix for the osteoporosis problem, calcium supplementation does make a lot of sense for most patients. There's considerable debate about the "ideal" form of supplemental calcium.
Calcium carbonate is the most prevalent, least expensive form, and it can be formulated into relatively small pills, making it very attractive to patients who are averse to pill-swallowing. But it is not very well absorbed unless you take it with food. "If you don't take it with your meals, you won't absorb all of it and all it will do is constipate you."
Protein-bound forms of calcium are generally better absorbed than calcium carbonate, and they don't cause gastrointestinal side effects. Dr. Masley has found they are very well tolerated, as is calcium citrate, which is also well absorbed, though not quite at the level of the protein-bound forms.
Of Coral & Contamination
There's another reason to be cautious with calcium carbonate: heavy metal contamination. According to an article published in JAMA, several years ago, one-third of calcium carbonate supplements sold in the US had measurable amounts of lead, in some cases significant levels. That's because oyster shells and coral are the primary sources of calcium carbonate, and unfortunately, our oceans are contaminated.
"The idea of 'natural source' calcium sounds great, but think about what an oyster wants? It wants lead in its shell. It wants arsenic. It likes any of those hard metals, because they make their shells harder. To an oyster, lead is great, and the same holds for coral," said Dr. Masley. "Why are we telling people to take coral calcium? Maybe this is one situation where synthetic is better."
The right amount of calcium is good; too much can be problematic, he said. It is not something one wants to load up on. More than 2,000 mg per day for long periods is associated with increased cancer risk, particularly prostate cancer. Excessive calcium intake also blocks absorption of other nutrients.
"Too often, doctors say, 'Take 1,500 mg of calcium in a supplement,' but they've never calculated the diet. The patient may already be getting 1,000 in their diet, from dairy, leafy greens and beans, so they're ending up taking 2,500 or 3,000, which may have adverse health effects. So we need to add supplements plus dietary intake, to come up with a reasonable daily plan." (For more on calcium, visit www.holisticprimarycare.net and read, Clearing Up Confusion About Calcium from our Summer 2005 edition.)
Magnesium: Often Overlooked
Magnesium deficiency is much more common than people realize, said Dr. Masley. In part this has to do with peoples' propensity to over-do it with calcium. "When you take calcium in excess, you block magnesium absorption. Since most Americans are already magnesium-deficient, if we're giving them calcium alone, we make the magnesium deficiency worse."
Magnesium is equally important as calcium for bone health, and it is also important for healthy bowel function. "For a lot of people who have GI trouble when they take calcium it is because they're not taking magnesium as well." Magnesium is also important for glucose control, because it is involved in insulin sensitivity, and is necessary for hundreds of different enzymes.
"You get it from whole grains, green leafies, and beans—foods Americans generally don't eat. We should be eating 'em but we don't."
The best-absorbed supplemental forms of magnesium are citrate, glycinate or a protein-bound form. Magnesium oxide, the most common form on the market, is a cathartic. "If you take enough, anyone will get diarrhea. The more you take the worse you feel," said Dr. Masley, adding that some patients experience GI distress from their cheap multivitamins. "If you look and see magnesium oxide as an ingredient, that's why. It's not well tolerated in the GI tract."
In terms of general guidelines, Dr. Masley said he looks for "about 400 mg/day in a typical diet." Anyone taking calcium supplements should also be taking magnesium, in a roughly 2 to 1 ratio. Many of the better multivitamin/multimineral products will provide this.
Iron: Too Little & Too Much
Dr. Masley has found that iron deficiency is a fairly common problem. "It doesn't kill any one, but you're just tired all the time, which is a big nation-wide problem." Deficiency is a problem for menstruating women and growing children. But generally speaking, iron excess is a bigger issue than iron deficiency, and many people are probably getting more iron than is healthy.
"If you give iron to women after menopause or to men, they 'rust' more quickly. Remember that iron is an oxidant. It causes irritation to tissues, and increases free radical formation. Men, and women after menopause, should not be on an iron supplement unless they are clearly anemic and deficient."
A lot of multivitamin/multimineral products have iron in them, and unless the patient is a reproductive age woman she probably does not need that. "Too often, I find my men and post-menopausal women taking extra iron that's probably not too good for them." The most common supplemental form is iron sulfate, which can cause GI distress in 20–25% of people.
The key food sources of iron include: green leafy veggies, legumes, beans, whole grains and, of course, red meat. Since Americans as a nation are fond of the latter, iron deficiency tends not to be as common as other mineral deficiencies. Contrary to popular belief (and meat industry marketing messages), vegetarians do not have higher rates of iron deficiency than the general population.
Selenium: A Help for the Elderly
Selenium deficiency is another common problem in the US, especially among the elderly. "If you're deficient, you tend to get sick more often," said Dr. Masley. Deficiency is very common in nursing home populations, and there are studies showing that selenium supplementation in the nursing home context reduces incidence of colds and flu. It even boosts flu shot titers in nursing home residents. "They actually have higher Influenza A titers when you give them 100 mcg selenium in food."
It also has a fairly promising track record in cancer prevention, particularly for cancer of the prostate. "Of all the minerals that the US Public Health Service has looked at, it's probably the one that has the most benefit in terms of cancer prevention. The maximum benefit from selenium for decreasing prostate risk is at about 200 mcg per day," he said. "I recommend supplementation with about 100–200 mcg. We do not have evidence-based guidelines other than for prostate cancer, and there's still some controversy over how effective it is."
Still, it's a low-risk intervention. Selenium is clearly safe at doses up to 300–400 mcg daily. Above that, it can be toxic.
Vitamin E: More from Food, Less from Capsules
As a population we both are and are not deficient in vitamin E, said Dr. Masley. Many Americans are taking a lot of supplemental vitamin E, and there's plenty of added E in our food supply, since it is a commonly added antioxidant. But we're not eating nearly enough of the foods naturally rich in vitamin E, such as nuts, olive and canola oils.
The problem is that 95% of all supplemental and food additive forms of vitamin E are d-alpha-tocopherol, which is only one of the 8 tocopherols and tocotrienols that comprise naturally-occurring vitamin E in foods.
Excessive amounts of d-alpha-tocopherol block absorption of gamma and delta tocopherols. "When we're giving people alpha tocopherol, we're actually blocking the other tocos from working. When we have a mixed array of nutrients and we give too much of one of them, we often end up making things worse," said Dr. Masley.
The irony is that d-alpha-tocopherol alone may not be all that healthy. "It lowers HDL, in particular HDL 2. And if you have low HDL to begin with—and that's 40% of the US population—you actually increase plaque growth and risk of cardiovascular events. So we make people worse, cardiac wise, when we give them excess alpha tocopherol." On the other hand, gamma and delta tocopherols actually raise HDL.
Generally speaking, though, there's no reason for people to supplement heavily with vitamin E, unless there's clear evidence of deficiency. What they should be doing, is increasing their intake of natural foods containing vitamin E complexes.
Masley's "Sweet 16"
Dr. Masley said there are 16 foods he strongly encourages his patients to eat more of: leafy greens, lean protein, seafood, beans, soy, whole grains, cruciferous vegetables, berries, nuts, flax, fresh garlic, herbs (oregano, rosemary, thyme, etc.) in abundance, green tea, unsweetened yogurt, red wine and chocolate.
Of the latter two, he noted that unless an individual has a history of alcoholism or other substance abuse issues, moderate daily intake of alcohol is fairly salutary. If you can keep it to one drink per day, that's good. Two is probably okay, though you do get extra calories. Three is definitely too much. Red wine clearly has the strongest evidence base.
As for chocolate, Dr. Masley advises patients to eat a small amount every day, provided that it is a good quality, minimally sweetened dark chocolate, with a minimum of 60% cocoa mass. "Seventy percent is best. It is a good fiber, and you'll drop BP, decrease LDL oxidations, release endorphins from brain, and decrease clotting." But gooey caramel filled, hyper-sweetened candy bars are definitely not part of the picture. "Cocoa is great, but don't confuse cocoa with candy!"
Want to Bring Nutrition into Your Practice? Try Group Sessions
"When we ask patients why they seek care from alternative practitioners, one of the most common answers we get is, 'We don't get enough nutrition advice from our primary care doctors.'"
|—Dr. Steven Masley |
Group sessions are an excellent way to integrate nutrition counseling into your practice—and get paid for it, said Steven Masley, MD, at the annual meeting of the American Academy of Family Physicians.
Ideally, nutrition counseling would be a central facet of primary care. "We should give out recipes as often as we give out prescriptions." said Dr. Masley, a family physician in St. Petersburg, Fla.
Unfortunately, many primary care doctors lack adequate training in nutrition, and even those who do have a grasp on it often find it difficult to bring into the clinic. That's because it can take a lot of time, and is not reimbursed as well as other aspects of primary care practice.
The solution? Teach patients what and how to eat in a group setting, said Dr. Masley, who has pioneered the group visit in family medicine. "It's a wonderful way to integrate nutrition into your practice and to have time to get into more detailed information." Patients often enjoy and benefit from the peer support that comes from group visits, and it optimizes your time, allowing you to help many more people than would be possible with individual visits.
It also has the added benefit of sparing you from having to repeat the same message over and over again.
Ten years ago, when mainstream medical organizations started to realize the extent to which Americans were seeking care from "alternative practitioners," many physicians' groups wondered why.
"When we ask them [patients], one of the most common answers we get is, 'We don't get enough nutrition advice from our primary care physicians.' So I think we really need to address our patients' needs. Help close that gap," Dr. Masley said.
Insurers and government funded health care plans are starting to recognize the importance of good nutrition guidance in managing the chronic diseases that are bankrupting our health care systems, and they are starting to pay for it. "You can get paid for doing group nutrition visits for patients with diabetes, cardiovascular risk, obesity, many other things."
Aside from the benefits it provides his patients, the nutrition counseling component brings a great deal of fun into Dr. Masley's practice. "I like to cook. It is really one of my passions. I definitely recommend sharing your favorite healthy recipes with your patients. Have a recipe of the month, promote those, give them out regularly, post 'em in your office."