Does Stevia Have Health Benefits?


The name “stevia” commonly refers to sweeteners derived from the leaves of Stevia rebaudiana Bertoni. Long before stevia gained popularity as an alternative sweetener, Stevia rebaudiana leaves were used by indigenous South Americans to sweeten beverages and medicines. The glycosides responsible for its sweet taste were isolated in 1931 and were later incorporated into stevia-based sweeteners.

The plant’s steviol glycosides have been estimated to be 100-300 times sweeter than sugar, meaning that only a small amount is needed to impart a sweet taste. Stevia is commonly used as a sugar alternative. The use of stevia in place of sugar significantly lowers the relative caloric and carbohydrate content of food and beverages. In addition to its use as an alternative sweetener, does stevia also offer other benefits for our health?

Analysis of extracts of stevia leaves revealed the presence of the flavonoids quercetin-3-O-arabinoside, quercitrin, apigenin, apigenin-4-O-glucoside, luteolin, and kaempferol-3-O-rhamnoside. Evaluation of the extracts’ free radical scavenging capacity determined that “Stevia rebaudiana may be useful as a potential source of natural antioxidants.”1

Stevia Makes a Better Sweetener

While saccharine’s taste is perceived to be less than ideal among some people and aspartame has been recently associated with weight gain in an animal model,2 stevia could be a better option as a sugar substitute. “We found that aspartame blocks a gut enzyme called intestinal alkaline phosphatase (IAP) that we previously showed can prevent obesity, diabetes and metabolic syndrome; so we think that aspartame might not work because, even as it is substituting for sugar, it blocks the beneficial aspects of IAP," explained Richard A. Hodin, MD, concerning the recent research conducted by his team at Massachusetts General Hospital. “Our findings regarding aspartame's inhibition of IAP may help explain why the use of aspartame is counterproductive.”

In a study in which aspartame, stevia and sucrose were consumed before lunch and dinner, stevia significantly lowered glucose levels following meals in comparison with sucrose and reduced post-meal insulin levels compared to sucrose as well as with aspartame.3

Potential Therapeutic Effects of Stevia

In a review of stevioside and related compounds, V. Chatsudthipong and C. Muanprasat of Mahidol University from Bangkok note that “A number of studies have suggested that, beside sweetness, stevioside along with related compounds, which include rebaudioside A (second most abundant component of S. rebaudiana leaf), steviol and isosteviol (metabolic components of stevioside) may also offer therapeutic benefits, as they have anti-hyperglycemic, anti-hypertensive, anti-inflammatory, anti-tumor, anti-diarrheal, diuretic, and immunomodulatory actions.”4

Stevia and Diabetes Research

The Journal of Diabetes Complications reported a study in which rats were pretreated with diets that contained stevia whole leaf powder, polyphenols or fiber, or no stevia for a month prior to being injected with a diabetes-inducing drug (streptozotocin). Animals that received stevia leaf or polyphenols exhibited lower blood glucose and liver enzymes compared to diabetic animals pretreated with a control diet.5 Those that received stevia leaf or polyphenols also showed improvements in glucose tolerance and insulin sensitivity and did not experience kidney damage from the diabetes-inducing drug, unlike control-fed diabetic rats.

An early human study of the effects of stevia extract involved 16 healthy subjects who were given stevia extract every six hours for three days while a control group received a different solution. Glucose tolerance tests were conducted and fasting glucose levels were measured before and after the treatment period. Those who received stevia had lower plasma glucose levels during glucose tolerance testing and decreased fasting glucose levels compared with pretreatment values.6

In a cross-over study involving 12 type 2 diabetics, stevioside supplementation lowered glucose levels after a meal, suggesting a potential use in the treatment of diabetic humans.7

A review of the potential roles of stevia in treating insulin resistance and diabetes notes that, “On the whole, researchers worldwide agree on the antidiabetic effects of Stevia; but they differ on how the effects contribute towards combating this metabolic disease . . . Some assert that Stevia’s utility is due to its antioxidant properties; this is supported by analysis of the phenols that may be extracted from the plant. Stevia has a large overall proportion of phenols, up to 91 mg/g; it is proposed that these constituents extracted from the leaves are the major agents contributing towards the antihyperglycemic activities exerted by the plant. This is further supported by the fact that the leaves have a greater ability to scavenge free radicals and prevent lipid peroxidation than controls […]”8

Stevia and High Blood Pressure Research

Research in rats and dogs suggests that stevioside “is an effective antihypertensive natural product.”9 The effect appears to be stronger in experimental hypertensive animals than those with normal blood pressure.10

When tested in a randomized, double-blind, placebo-controlled trial of 106 men and women with hypertension, stevioside consumed three times per day was associated with a mean reduction in systolic blood pressure of 12 mmHg and an average diastolic reduction of 8 mmHg from baseline values after three months—a benefit that continued throughout the course of the 12 month study.11

Those who received a placebo experienced changes in blood pressure that were not significantly different than those measured at the beginning of the trial. “Stevioside was found to be a safe and effective compound in the treatment of hypertension although the amplitude of blood pressure lowering was slightly less than other antihypertensive drugs,” note Paul Chan and colleagues. “It could therefore be used as a supplementary therapy since it has already been used as a taste-modifying agent for more than two decades.”

A subsequent two year randomized, double-blind, placebo-controlled trial of stevioside in subjects with mild essential hypertension resulted in an average decline in systolic blood pressure of 10 mmHg and 6 mmHg diastolic blood pressure, improved quality of life and a lower incidence of the development of left ventricular hypertrophy compared with the placebo group at the end of the treatment period.12

In adults with normal and low-normal blood pressure, as much as 1,000 milligrams per day of rebaudioside A from stevia did not affect resting, seated, systolic, diastolic or mean arterial blood pressure or heart rate, which suggests that stevia may not lower blood pressure among those who don’t have hypertension.13

Stevia May Help Protect Teeth

Stevia has other benefits such as helping to prevent dental caries when used in place of sugar.14 In addition to helping to eliminate the acidic effect of sugar on tooth enamel, stevia helps inhibit some of the caries-causing bacteria.15

Stevia and stevioside appear to not only be nontoxic alternative sweeteners when used in moderation, but to benefit specific health conditions and help protect the teeth when used as a sugar substitute.

Stevia Safety

“Acute and subacute toxicity studies revealed a very low toxicity of Stevia and stevioside,” writes J. M. Geuns in a review published in the journal Phytochemistry.16 “The conclusion is that Stevia and stevioside are safe when used as a sweetener. It is suited for both diabetics, and phenylketonuric patients, as well as for obese persons intending to lose weight by avoiding sugar . . . No allergic reactions to it seem to exist.”

References:

  1. Ghanta S et al. J Agric Food Chem. 2007 Dec 26;55(26):10962-7.
  2. Gul SS et al. Appl Physiol Nutr Metab. 2016 Nov 18.
  3. Anton SD et al. Appetite. 2010 Aug;55(1):37-43.
  4. Chatsudthipong V et al. Pharmacol Ther. 2009 Jan;121(1):41-54.
  5. Shivanna N et al. J Diabetes Complications. 2013 Mar-Apr;27(2):103-13.
  6. Curi R et al. Braz J Med Biol Res. 1986;19(6):771-4.
  7. Gregersen S et al. Metabolism. 2004 Jan;53(1):73-6.
  8. Mohd-Radzman NH et al. Evid Based Complement Alternat Med. 2013;2013:718049.
  9. Liu JC et al. Pharmacology. 2003 Jan;67(1):14-20.
  10. Hsu YH et al. Zhonghua Yi Xue Za Zhi (Taipei). 2002 Jan;65(1):1-6.
  11. Chan P et al. Br J Clin Pharmacol. 2000 Sep;50(3):215-20.
  12. Hsieh MH et al. Clin Ther. 2003 Nov;25(11):2797-808.
  13. Maki KC et al. Food Chem Toxicol. 2008 Jul;46 Suppl 7:S40-6.
  14. Ferrazzano GF et al. Molecules. 2015 Dec 26;21(1):E38.
  15. Giacaman RA et al. Arch Oral Biol. 2013 Sep;58(9):1116-22.
  16. Geuns JM. Phytochemistry. 2003 Nov;64(5):913-21.

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If You Use a Computer or Smartphone, Read This!


Chances are, you’re reading this article on a computer monitor or other electronic device. As of 2014, 1 over 80% of the population in the United States, Canada, and the UK and other European countries had an internet connection.

While some people use computers or smartphones to check email or social media sites, for others, their livelihood depends upon it. Spending eight or more hours in front of a computer monitor five days per week is the norm for a growing number of working individuals.

Although many people are aware of the damaging effects to the eyes caused by the sun’s ultraviolet rays, not everyone realizes the danger of chronic exposure to blue light emitted by electronic devices. While sunlight consists of approximately 25% to 30% blue light, computer monitors and other electronic device screens (particularly light-emitting diodes, or LEDS) emit about 35% blue light. Additionally, modern lighting involves ever-greater use of LEDs as well as compact fluorescent lamps that emit about 25% blue light. According to an article appearing in the Review of Optometry, “. . . our exposure to blue light is every­where and only increasing.”2

Blue light induces photochemical stress that damages cells in the eyes’ retina which can lead to their destruction. The retina is a nerve cell layer in the back of the eye that contains neurons known as photoreceptors (rods and cones) that sense light, resulting in impulses that are transmitted via the optic nerve to the brain.

The retinal pigment epithelium (RPE) is a layer of pigmented cells next to and outside of the retina that nourishes retinal nerve tissue and transports molecules into the retina and out of it. The RPE contains a high amount of the carotenoids lutein, zeaxanthin and meso-zeaxanthin. These pigments have been characterized as forming “a kind of biological sunglasses that absorb blue light.”3

Of all the carotenoids that are absorbed by the human body, only lutein, zeaxanthin and meso-zeaxanthin accumulate in the macula, an area at the center of the retina responsible for central vision.4 In addition to their blue-light filtering property, these pigments have antioxidant and anti-inflammatory activities, all of which help protect against age-related macular degeneration (AMD), a leading cause of vision loss in older men and women. Macular pigment density is considered to be a significant indicator of retinal health.

A randomized, double-blinded, placebo-controlled trial reported in BioMed Research International found an increase in macular pigment optical density and contrast sensitivity among those who received lutein and zeaxanthin for two years.5 Another study of early AMD patients found increases in macular pigment after three years of supplementation with lutein, zeaxanthin and meso-zeaxanthin.6 These and other trials have demonstrated that supplementation with the three carotenoids can improve macular pigment optimal density, thereby helping to protect the retina. In fact, a meta-analysis of 20 randomized trials including a total of 938 AMD patients and 826 subjects without the disease concluded that supplementation with lutein, zeaxanthin and meso-zeaxanthin improved macular pigment optical density in both AMD patients and healthy subjects.7

Findings from the original Age-Related Eye Disease Study (AREDS) resulted in the widespread recommendation of vitamin C, vitamin E, zinc with copper, and beta carotene supplementation to reduce the development of advanced age-related macular degeneration. However, in AREDS-2, the replacement of beta carotene with lutein and zeaxanthin was associated with greater protection against the progression to late AMD than that conferred by the original AREDS formula.8

While one can’t avoid exposure to blue light these days, protecting oneself may be as simple as adding lutein, zeaxanthin and meso-zeaxanthin to one’s supplemental regimen. Although these nutrients occur in foods like spinach, kale and, in the case of meso-zeaxanthin, certain fish, nutritional supplements are now available that make it easy to obtain optimal amounts of these important carotenoids on a daily basis.

“The naturally occurring retinal antioxidants, such as lutein and zeaxanthin, can’t be regenerated fast enough to keep pace with the amount of damaging blue-light saturating the immediate environment,” commented Life Extension’s Senior Health Scientist Michael A. Smith, MD. “We are all quickly becoming lutein deficient. And since the blue-light emitting devices aren’t going anywhere, the risk of macular degeneration is rising. Macular pigment density must be preserved with daily lutein and zeaxanthin supplementation.”

References:

  1. 1. Available at http://www.internetlivestats.com/internet-users/ Accessed January 5, 2017.
  2. 2. Melton R. Rev Optom. CE. 2014 Feb.
  3. 3. Strauss O. Physiol Rev. 2005 Jul;85(3):845-81.
  4. 4. Loskutova E et al. Nutrients. 2013 Jun; 5(6): 1962–1969.
  5. 5. Huang YM et al. Biomed Res Int. 2015;2015:564738.
  6. 6. Akuffo KO et al. Eye (Lond). 2015 Jul;29(7):902-12.
  7. 7. Ma L et al. Nutrients. 2016 Jul 12;8(7):426.
  8. 8. Age-Related Eye Disease Study 2 (AREDS2) Research Group. JAMA Ophthalmol. 2014 Feb;132(2):142-9.

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Are You Protected From Pesticides?


If you think you’re protected against pesticide exposure by going organic, think again.

Pesticides are so prevalent in our environment that they’re found in the air we breathe. Some, like DDT, linger in the environment for decades.

Washing your produce doesn’t always reduce pesticide residues. Nowadays systemic pesticides are combined with fertilizer and absorbed by plants’ vascular system, making it impossible for these compounds to be rinsed away.

By their very nature, pesticides are toxic to living beings. They impact the nervous systems of their intended victims as well as those of humans. High amounts of DDE, a DDT metabolite, have been measured in the brains of Alzheimer’s disease patients, and greater than four-fold higher average levels of another pesticide, beta-hexachlorocyclohexane, have been detected in the serum of those with Parkinson’s disease in comparison with healthy individuals.1,2

Pesticide exposure has also been linked to an increased risk of cancer, endocrine complications, infertility, respiratory disorders, organ failure, birth defects, and more.

While exposure to pesticides may be inevitable, there is something that can be done to protect oneself. A naturally occurring compound in onions, apples and other plant foods has been shown in experimental research to protect against some of pesticides’ harmful effects.3,4

Flavonoids (which include a class known as flavonols) are manufactured by plants to protect themselves from harm. The flavonol quercetin has been found to have a protective effect against the adverse effects of common types of pesticides.

Quercetin has been demonstrated to protect against damage caused by organophosphate pesticides, which are a danger to humans as well as wildlife (including bees). High dose quercetin has been shown to protect against organophosphate toxicity by preserving energy, fatty acid and sex hormone metabolism; lowering oxidative stress, protecting DNA, and helping to preserve liver and kidney function.3

In a study involving human cells treated with the organophosphate pesticide dichlorvos (DDVP), pretreatment with quercetin reduced DDVP-induced cell death, inhibited the generation of reactive oxygen species and lowered lipid peroxidation.5

Other research has demonstrated a protective effect for quercetin against neurotoxicity induced by the insecticide endosulfan. 6 According to the authors, pretreatment with quercetin protected brain mitochondria (the cell’s “powerhouses”) from oxidative stress, lipid peroxidation and swelling caused by the pesticide.

Paraquat is an herbicide used to kill unwanted plant growth. Due to its action against oxidative stress (a primary mechanism of paraquat’s toxicity), quercetin has been suggested as a potential protective agent.7

In addition to quercetin’s protective effect against pesticide exposure, the compound may provide a number of additional health benefits. “Given quercetin’s positive effect on the immune response and its DNA protective properties, we should consider it as a longevity nutrient,” remarked Life Extension’s Senior Health Scientist Michael A. Smith, MD.

Even the best of diets may fail to provide optimal amounts of quercetin and other nutrients. Those who wish to ensure themselves of continuous protection against pesticides find that quercetin supplements are an easy option to consume at home or on the go. Although we may not be able to avoid exposure to pesticides in our environment, we can avoid some of the consequences through this simple protective measure.

References:

  1. 1. Richardson JR et al. JAMA Neurol. 2014 Mar;71(3):284-90.
  2. 2. Richardson JR et al. Arch Neurol. 2009;66(7):870-5.
  3. 3. Li et al. Xenobiotica. 2016;46(3):225-33.
  4. 4. Qi L et al. Hum Exp Toxicol. 2016
  5. 5. Ben Salem I et al. Cell Stress Chaperones. 2016 Jan;21(1):179-86.
  6. 6. Lakroun Z et al. Environ Sci Pollut Res Int. 2015 May;22(10):7776-81.
  7. 7. Blanco-Ayala T et al. Free Radic Res. 2014 Jun;48(6):623-40.

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Meditative Running: How To Find Your Zen

Jesse Silkoff

Runners frequently injure themselves when they stop listening to their bodies. In fact, many runners require training to help them interpret internal signals—warning signs that they’re taxing their muscles and putting themselves at risk of injury.

Unfortunately, we live in a very results-obsessed world. In our urge to compete and our impatience to be better, faster, and stronger, it can become easy for runners to project themselves into visions of future success—rather than focusing on the everyday work of training.

Meditative or mindful running offers a counterpoint to that philosophy—and in many ways, an alternative to the stress and hustle of day-to-day life. Mindful running posits that we can learn to be more efficient and harmonious runners by observing the body, without attempting to adjust our form, or push ourselves harder to go faster.

And just like strength training, mindfulness can be perfected through habit. Here are a few ways you can incorporate meditative practices into your running today.

Pay Attention to Your Breath

Most meditation practices begin by simply observing the breath. As the Buddhist Centre illuminates: “by focusing on the breath you become aware of the mind’s tendency to jump from one thing to another. The simple discipline of concentration brings us back to the present moment and all the richness of experience that it contains.”

To really dial in to your running, start by listening to your breathing. How does your breath align with the motion of your body? Are your steps out of sync with the rhythm of your inhales and exhales? Don’t try to make any changes right now. Just listen. Try to focus your attention on your breathing—instead of allowing your mind to wander.

Practice Observing

Once you’ve spent some time with your breathing, move to your body. For this part, you’ll use an adaptation of a progressive muscle relaxation meditation. Focus your attention slowly from the top of your head, neck and shoulders all the way down to your feet, taking time to observe each part of your body. Pay attention to your form—are you holding your neck stiffly? Are you leaning forward?

Also notice any muscle pain or soreness. How do your muscles feel as you run? As you move through your body, bringing awareness to each part, allow yourself to sense without judgment. Just get to know your body and feel how it’s doing today.

Adjusting Your Form

Next, we’ll make some adjustments to help you run more freely. If you’re tensing up as you run, holding your neck and arms stiffly, let them loosen up. Check that you’re not clenching your fists, as well—your hands should be relaxed enough that you could hold a potato chip in each one without crushing it.

You may also notice that you’re bouncing up and down or leaning forward in an attempt to go faster or work harder. Try to adjust your form so that you’re moving seamlessly through the air, and so that your feet work rhythmically with your breath.

Abandon “Joyless Striving”

I have a yoga teacher who likes to talk about “joyless striving,” a state of pushing ourselves toward a goal without taking pleasure in the process of getting there. Often, this kind of clenching of the will is a sign that we’re pushing ourselves too hard.

Running should be a process—not a one-and-done event—so give yourself the freedom to experience your workout without trying to get it all done in one sprint. After all, just like Rome wasn’t built in a day, you can’t be ready to run a marathon after one run.

When you begin thinking of your runs as a practice, rather than a means to an end, you’ll see fewer injuries and have better form. And you may just enjoy running more, too!

Jesse Silkoff is President and Co-Founder of FitnessTrainer, the leading online marketplace to find a local personal trainer that can help you achieve your health and wellness goals.

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Should You Supplement with Calcium?


Headlines concerning the use of calcium supplements sway back and forth like palm trees in the wind. The reason behind this confusing phenomenon has to do more with irresponsible media jumping on the latest news release with a desire to grab as much attention as possible than with evidence provided by sound studies.

After years of hearing about the importance of supplementing with calcium from doctors and other experts concerned about the “silent epidemic” of osteoporosis, a meta-analysis published in the British Medical Journal in 2010 raised the concern that supplementation with the mineral, having been associated by the researchers with admittedly modest increases the risk of cardiovascular disease, ”might translate into a large burden of disease in the population.”1

The meta-analysis, which evaluated data from 8,151 participants in 15 trials, found that, of 296 subjects who had heart attacks, 166 were receiving calcium and 130 received a placebo, resulting in a 27% increase in the relative risk in those receiving calcium.

The journal subsequently published letters received, concerning the conclusions of the researchers involved in the analysis, while other sources of information, including Life Extension®, published their own analysis of the findings and offered possible explanations, such as a lack of co-supplementation with vitamin D, exclusion of trials that found reductions rather than increases in cardiovascular disease in association with calcium supplementation, and other potential factors. Yet the damage had been done, the public had read the popular news media headlines.

Why is Calcium Important?

Calcium is an essential mineral, meaning that it is necessary to human life and health. Unlike some vitamins, minerals are not made in the body and must be obtained in the diet. Also unlike some vitamins, minerals do not readily wash out of the body and can accumulate to undesirably elevated levels if too much is consumed over a prolonged period.

Calcium is also used every second of our lives to maintain the proper pH of the blood. It is the most abundant mineral of the body and forms a major part of the bones. It also forms a part of atherosclerotic plaques that narrow the arteries.

It has been known for some time that the bones need more than just calcium, and that magnesium, and vitamins D and K, are needed to keep calcium in the skeleton and out of the arterial walls. Therefore, adding these nutrients is recommended for those who supplement with calcium.

The Research on Calcium

A more recent meta-analysis published in 2016 that included 22 randomized controlled trials and 4,071 participants found a decrease in low-density lipoprotein (LDL) and an increase in high-density lipoprotein (HDL) cholesterol in association with calcium supplementation with or without vitamin D, thereby reducing major risk factors for cardiovascular disease and heart attack.2

A study of postmenopausal women who received calcium citrate supplements found lower LDL, higher HDL and greater HDL to LDL ratios after a year.3 "As a result, calcium citrate may reduce the incidence of heart attacks and angina in postmenopausal women,” commented lead researcher Ian R. Reid, who is a professor at the University of Auckland’s Department of Medicine. “Based on our data, one could predict that calcium citrate supplements may help otherwise healthy postmenopausal women reduce cholesterol, improve heart health and possibly even reduce the rate of cardiovascular related events by 20 to 30 percent. These data provide reason to encourage the more widespread use of calcium supplementation in postmenopausal women.”

Notably, among 34,486 postmenopausal women who participated in the Iowa Women’s Healthy Study, those whose total calcium intake was among the top 25% of subjects had a 33% lower risk of death from ischemic heart disease than those whose intake was among the lowest 25%.4 The risk reduction in association with high calcium supplement intake but low dietary calcium intake was 34%.

In 2014, the American Journal of Clinical Nutrition reported the results of a study that followed participants in the Diabetes Heart Study for an average of 9.4 years. Computed tomography (CT) scans of the coronary and carotid arteries, and abdominal aorta failed to find an association between any measure of calcified plaque and calcium intake from supplements or diet.5 In fact, calcium supplementation among women was associated with a 38% lower adjusted risk of mortality from any cause over a 9.4 year average follow-up period. "Studies have raised concerns that calcium supplementation may have the unintended negative consequence of increasing cardiovascular disease risk," authors Laura M. Raffield and her colleagues observed. "In this study, we did not observe any negative cardiovascular disease impacts of differing calcium intakes from diet and supplements in contrast to some previous reports. Instead, calcium supplement use was associated with lower all-cause mortality risk in women."

The Bottom Line

In October 2016, the National Osteoporosis Foundation and the American Society for Preventive Cardiology issued a new evidence-based guideline stating that calcium from supplements or food that doesn’t exceed the tolerable upper intake level is safe for the heart.6 In an article in the Annals of Internal Medicine titled, “Lack of Evidence Linking Calcium With or Without Vitamin D Supplementation to Cardiovascular Disease in Generally Healthy Adults: A Clinical Guideline From the National Osteoporosis Foundation and the American Society for Preventive Cardiology,” S. L. Kopecky and colleagues announce that, “In light of the evidence available to date, calcium intake from food and supplements that does not exceed the tolerable upper level of intake (defined by the National Academy of Medicine as 2000 to 2500 mg/day) should be considered safe from a cardiovascular standpoint.”

The new guideline was released simultaneously in the journal with the outcome of a systematic review and meta-analysis of four randomized trials and 27 observational studies.7 According to authors M. Chung and colleagues, “The trials did not find statistically significant differences in risk for CVD events or mortality between groups receiving supplements of calcium or calcium plus vitamin D and those receiving placebo. Cohort studies showed no consistent dose-response relationships between total, dietary, or supplemental calcium intake levels and cardiovascular mortality and highly inconsistent dose-response relationships between calcium intake and risks for total stroke or stroke mortality.”

There are other studies such as these. Other studies demonstrate the benefit of calcium supplementation for protection against osteoporosis, colorectal cancer and more. However, if you choose to supplement with calcium, make sure that you stay below the tolerable upper level of calcium intake from supplements and diet combined, and add a healthy amount of magnesium, vitamin D and vitamin K. Calcium may be one of the few nutrients for which it is not necessary to exceed the current recommended dietary allowance to achieve optimal nutrition.

References:

  1. 1. Bolland MJ et al. BMJ. 2010 Jul 29;341:c3691.
  2. 2. Chen C et al. J Cardiovasc Nurs. 2016 Nov 18.
  3. 3. Reid IR et al. 2002 Apr 1;112(5):343-7.
  4. 4. Bostick RM et al. Am J Epidemiol. 1999 Jan 15;149(2):151-61.
  5. 5. Raffield LM et al. Am J Clin Nutr. 2014 Oct;100(4):1029-35.
  6. 6. Kopecky SL et al. Ann Int Med. 2016 Oct 25.
  7. 7. Chung M et al. Ann Intern Med. 2016 Oct 25.

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